Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review."

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Treadmill training is increasingly recognized as a potential intervention to improve balance and reduce fall risk in this population. This systematic review evaluates the effectiveness of treadmill training on balance in the elderly. Methods A comprehensive search was conducted in databases including MEDLINE, EMBASE, CINAHL Plus, PEDro, Cochrane Library, and ERIC from January 1, 1980, to January 1, 2025. The search focused on treadmill training’s impact on balance in older adults. From 74 identified studies, primary outcome measure was “Balance Improvement, risk of fall” and secondary were “Cognitive Function and Quality of Life,” and others. Articles were excluded for reasons like irrelevance to treadmill training, language barriers, or duplication, resulting in 16 final studies. Results Treadmill training demonstrated positive effects on balance and fall risk reduction, particularly in elderly individuals with Parkinson’s disease, spinal cord injuries, and age-related balance issues. Perturbation-based treadmill training significantly reduced fall rates, while underwater treadmill sessions improved mobility and cognitive function. Conclusion Treadmill training interventions are promising for improving balance and mobility in the elderly, including those with Parkinson’s disease, spinal cord injuries, and age-related balance issues. While these interventions show potential, further research is needed to determine optimal protocols, durations, and combinations with other interventions. This could lead to a more comprehensive approach for addressing balance and mobility challenges in the elderly, promoting healthy aging and reducing fall risks. 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F1000Research 2025, 13 :330 ( https://doi.org/10.12688/f1000research.146583.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Revised Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] Previous Title 'A systematic review evaluating the efficacy of treadmill training in geriatric care as an intervention for improving balance and reducing fall risks in elderly population' Ayman Mohammed Ismail Zafer 1 , Alsayed Abdelhameed Shanb https://orcid.org/0000-0002-4878-5025 2 , Matar AbduAllah Alzahrani 2 , Ankita Sharma 3 , Moattar Raza Rizvi https://orcid.org/0000-0001-8424-7163 3 Ayman Mohammed Ismail Zafer 1 , Alsayed Abdelhameed Shanb https://orcid.org/0000-0002-4878-5025 2 , [...] Matar AbduAllah Alzahrani 2 , Ankita Sharma 3 , Moattar Raza Rizvi https://orcid.org/0000-0001-8424-7163 3 PUBLISHED 10 Feb 2025 Author details Author details 1 Physical Therapy Department, Taibah University, Medina, Al Madinah Province, 41411, Saudi Arabia 2 Physical Therapy Department, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, 34212, Saudi Arabia 3 Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, Haryana, 121004, India Ayman Mohammed Ismail Zafer Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation Alsayed Abdelhameed Shanb Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation Matar AbduAllah Alzahrani Roles: Conceptualization, Formal Analysis, Project Administration, Resources, Writing – Original Draft Preparation Ankita Sharma Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Resources, Writing – Original Draft Preparation Moattar Raza Rizvi Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Global Public Health gateway. Abstract Background & Purpose Falls and balance issues are significant concerns for the elderly. Treadmill training is increasingly recognized as a potential intervention to improve balance and reduce fall risk in this population. This systematic review evaluates the effectiveness of treadmill training on balance in the elderly. Methods A comprehensive search was conducted in databases including MEDLINE, EMBASE, CINAHL Plus, PEDro, Cochrane Library, and ERIC from January 1, 1980, to January 1, 2025. The search focused on treadmill training’s impact on balance in older adults. From 74 identified studies, primary outcome measure was “Balance Improvement, risk of fall” and secondary were “Cognitive Function and Quality of Life,” and others. Articles were excluded for reasons like irrelevance to treadmill training, language barriers, or duplication, resulting in 16 final studies. Results Treadmill training demonstrated positive effects on balance and fall risk reduction, particularly in elderly individuals with Parkinson’s disease, spinal cord injuries, and age-related balance issues. Perturbation-based treadmill training significantly reduced fall rates, while underwater treadmill sessions improved mobility and cognitive function. Conclusion Treadmill training interventions are promising for improving balance and mobility in the elderly, including those with Parkinson’s disease, spinal cord injuries, and age-related balance issues. While these interventions show potential, further research is needed to determine optimal protocols, durations, and combinations with other interventions. This could lead to a more comprehensive approach for addressing balance and mobility challenges in the elderly, promoting healthy aging and reducing fall risks. READ ALL READ LESS Keywords Elderly, balance, treadmill training, falls prevention, aging Corresponding Author(s) Moattar Raza Rizvi ( [email protected] ) Close Corresponding author: Moattar Raza Rizvi Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Zafer AMI et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Zafer AMI, Shanb AA, Alzahrani MA et al. Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.12688/f1000research.146583.2 ) First published: 23 Apr 2024, 13 :330 ( https://doi.org/10.12688/f1000research.146583.1 ) Latest published: 10 Feb 2025, 13 :330 ( https://doi.org/10.12688/f1000research.146583.2 ) Revised Amendments from Version 1 In this revised version of the manuscript, substantial updates have been made to enhance clarity, accuracy, and alignment with the objectives of the systematic review. The title was revised to "Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review," replacing “geriatric care” with “elderly population” for a more precise and focused scope. The abstract now reflects an updated search strategy extending to January 1,2025. Although no additional studies meeting the inclusion criteria were identified, the revised results explicitly highlight fall risk reduction as a key outcome, aligning with the title and research objectives. Criteria for excluded articles were relocated from the abstract to the Methodology section for improved organization. In the Introduction, all text was revised to ensure consistency in past tense and third-person narration, avoiding first-person language. The Methodology section now incorporates the updated PRISMA2020 flowchart, detailing the identification of studies via databases, registers, and other sources. Methods for duplicate removal, data extraction, and quality assessment have been explicitly described, including the use of the Risk of Bias Tool (RoB2.0) with visual summary and traffic plots for enhanced transparency. The Results section reconciles discrepancies in the number of included studies, confirming the correct count as15. Methodological quality assessments are now explicitly reported, ensuring a robust evaluation of study rigor. The Discussion has been significantly expanded to provide a comprehensive synthesis of findings, emphasizing treadmill training’s effects on balance and fall risk reduction, along with its impact on secondary outcomes like cognitive function and quality of life. Implications for clinical practice and research gaps are thoroughly addressed. Finally, Table 1 was reorganized for clarity and conciseness, combining columns, updating study classifications, and adding contextual details like participant age and study setting. In this revised version of the manuscript, substantial updates have been made to enhance clarity, accuracy, and alignment with the objectives of the systematic review. The title was revised to "Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review," replacing “geriatric care” with “elderly population” for a more precise and focused scope. The abstract now reflects an updated search strategy extending to January 1,2025. Although no additional studies meeting the inclusion criteria were identified, the revised results explicitly highlight fall risk reduction as a key outcome, aligning with the title and research objectives. Criteria for excluded articles were relocated from the abstract to the Methodology section for improved organization. In the Introduction, all text was revised to ensure consistency in past tense and third-person narration, avoiding first-person language. The Methodology section now incorporates the updated PRISMA2020 flowchart, detailing the identification of studies via databases, registers, and other sources. Methods for duplicate removal, data extraction, and quality assessment have been explicitly described, including the use of the Risk of Bias Tool (RoB2.0) with visual summary and traffic plots for enhanced transparency. The Results section reconciles discrepancies in the number of included studies, confirming the correct count as15. Methodological quality assessments are now explicitly reported, ensuring a robust evaluation of study rigor. The Discussion has been significantly expanded to provide a comprehensive synthesis of findings, emphasizing treadmill training’s effects on balance and fall risk reduction, along with its impact on secondary outcomes like cognitive function and quality of life. Implications for clinical practice and research gaps are thoroughly addressed. Finally, Table 1 was reorganized for clarity and conciseness, combining columns, updating study classifications, and adding contextual details like participant age and study setting. See the authors' detailed response to the review by Mohamed Salaheldien Alayat See the authors' detailed response to the review by Adel Alhusaini READ REVIEWER RESPONSES Background As the global population of older adults and elderly individuals continues to rise, there is a growing emphasis on innovative approaches to enhance their well-being, with a particular focus on addressing the challenges of aging. The aging population presents a unique set of opportunities and challenges, and by embracing innovative solutions, we can transform the aging experience, prolong vitality, and usher in a new era of longevity and well-being ( Rudnicka et al., 2020 ; Amuthavalli Thiyagarajan et al., 2022 ; Officer and de la Fuente-Núñez, 2018 ). Some key areas of innovation in addressing the challenges of aging include genetic therapies and stem cell regeneration, which hold great potential for improving health and function in older adults, potentially reversing age-related declines and promoting a more youthful state ( Garay, 2023 ; Negredo et al., 2020 ). Additionally, artificial intelligence and wearable technology can be used to monitor and manage health, providing valuable data for healthcare professionals and individuals to make informed decisions about their well-being ( Wang and Hsu, 2023 ; Bohr and Memarzadeh, 2020 ; Bajwa et al., 2021 ). Virtual reality technology offers a wealth of opportunities for the aging population, enabling them to engage in stimulating activities, travel to distant places, and socialize with others, regardless of physical limitations, thus promoting mental well-being and combating feelings of isolation and loneliness ( Chaze et al., 2022 ; Lin et al., 2018 ). Aging in place strategies focus on enhancing the safety and quality of life for older adults in their home environment, allowing them to participate in valued activities and maintain their independence. One of the most promising areas of development is the field of exercise interventions, notably treadmill training. This approach is gaining traction as a means to counteract the age-related declines in physical function, balance, and mobility that significantly influence the quality of life and independence of older individuals ( Brach and VanSwearingen, 2013 ; VanSwearingen et al., 2011 ). Treadmill training for the elderly is particularly advantageous because it can be tailored to individual needs and physical capabilities. It offers a safe and controlled environment for exercise, which is crucial for those with diminished balance or mobility. Regular use of the treadmill can lead to improvements in balance and coordination, thereby reducing the risk of falls, a common and serious concern among the elderly ( Oddsson et al., 2007 ). Additionally, treadmill exercises are beneficial for cardiovascular health, helping to keep the heart healthy and potentially reducing the risk of heart-related diseases, which are more common in older age ( Chen et al., 2022 ; Tian and Meng, 2019 ; Pinckard et al., 2019 ; Rebelo-Marques et al., 2018 ). Moreover, engaging in treadmill workouts can help maintain or increase muscle strength and bone density, countering the natural decline that accompanies aging. This type of physical activity is also associated with mental health benefits, including a reduction in symptoms of depression and anxiety, which are significant issues for many older adults ( Izquierdo et al., 2021 ; Zhu et al., 2023 ). Another aspect of treadmill training that makes it suitable for older populations is its customizability. Treadmill exercises can be adjusted in terms of speed, incline, and duration to match the individual’s fitness level and physical limitations. This adaptability, combined with the safety features of modern treadmills, like safety rails and emergency stop mechanisms, ensures a safe workout environment. In addition to physical benefits, treadmill training can also offer social benefits, especially when conducted in group settings such as classes or gym environments. It provides an opportunity for social interaction and engagement, which is important for the mental health and overall well-being of older adults. Furthermore, the integration of technology in modern treadmills, including heart rate monitors and personalized training programs, allows for more tailored and monitored exercise sessions, enhancing both safety and efficacy ( Shepherd et al., 2015 ; Prichard and Tiggemann, 2008 ). However, it is critical that any exercise regimen, including treadmill training, be developed in consultation with healthcare professionals. This ensures that the exercises are not only beneficial but also safe, particularly for those with pre-existing health conditions. A personalized approach ensures that the older adults reap the maximum benefits from their exercise routines without compromising their health. The growing interest in the geriatric population’s health and well-being is evident in the expanding research on treadmill training’s potential benefits for older adults and the elderly ( McPhee et al., 2016 ). This research recognizes the complex interplay of physiological, neuromuscular, and psychological factors unique to this age group. These factors play a crucial role in how older adults respond to various interventions, including exercise ( de Souto Barreto et al., 2016 ; Paterson et al., 2007 ). Treadmill training, as a focused research area, has been the subject of numerous studies that span different years, geographical locations, and demographic profiles. These studies are not just limited in scope; they encompass a broad range of objectives and outcomes. One of the key areas of investigation is the impact of treadmill training on postural stability in the elderly. This aspect is crucial because maintaining a good postural balance is fundamental to performing everyday activities and reducing the risk of falls, which are a significant health concern in this age group ( Pereira et al., 2020 , 2021 ; Hirjaková et al., 2020 ). Another important research focus is the effect of treadmill training on gait patterns ( Newell et al., 2012 ; Almutairi, 2023 ; van Ooijen et al., 2013 ; Wnuk et al., 2010 ). As people age, their walking patterns can change, often becoming slower and less steady. These changes in gait can lead to an increased risk of falls and injuries. Treadmill training can potentially help in modifying these gait patterns, leading to safer and more efficient walking. Additionally, researchers are examining how treadmill training influences the rate of falls among the elderly ( van Ooijen et al., 2016 ). Falls are not only a leading cause of injury in older adults but also contribute to a fear of falling, which can significantly reduce their activity levels and quality of life. By improving balance, strength, and gait through treadmill training, there is a possibility of reducing the incidence of falls, thus enhancing the overall safety and independence of the elderly ( Cadore et al., 2013 ; Marsh et al., 2006 ). Moreover, the psychological impacts of treadmill training are also a subject of study. Regular physical activity has been associated with improvements in mood, cognitive function, and general mental well-being. For the elderly, these psychological benefits are as important as the physical ones, considering the high prevalence of depression, anxiety, and cognitive decline in this age group ( Afifi et al., 2023 ; Dorfman et al., 2014 ). The diversity of these research studies reflects the multifaceted nature of aging and the need for a comprehensive approach to health and wellness in the geriatric population. By exploring various outcomes and considering the unique challenges faced by older adults, these studies contribute significantly to our understanding of how best to support the health and well-being of the elderly through targeted interventions like treadmill training. Figure 2. Risk of Bias Assessment. The traffic plot (top) shows domain-specific risk assessments for each study, categorized as low risk, some concerns, or high risk across five domains. The summary plot (bottom) depicts the proportion of studies at each risk level, highlighting overall methodological rigor with most studies showing low risk in outcome measurement and reporting. The focus of this systematic review was to delve deep into the myriad of studies on treadmill training for older adults, aimed to synthesize and consolidate the diverse findings into a coherent understanding. This undertaking recognizes that understanding the mechanisms behind the observed outcomes in these studies is critical for fully realizing the potential benefits of treadmill training for the elderly. Treadmill training, with its unique ability to simultaneously engage both motor and cognitive systems, presents a promising avenue for holistic geriatric care. However, the diversity in research methodologies and outcomes necessitates a careful and comprehensive analysis to identify meaningful patterns and insights. This review, therefore, meticulously examines various aspects of the studies, including intervention protocols, study designs, and outcome measures. The goal is to identify commonalities and trends that transcend individual studies, thereby providing a more comprehensive understanding of treadmill training’s role in geriatric healthcare. A crucial aspect of this review is the acknowledgment of the intricate relationship between physical activity and cognitive function in aging. The cognitive benefits of physical exercise, particularly in an aging population, are an area of growing interest. Treadmill training, by demanding both physical and cognitive engagement, could potentially enhance cognitive function alongside physical health, offering dual benefits to the elderly. Furthermore, this review traverses the historical landscape of treadmill training research, encompassing a broad spectrum of studies that have investigated its physiological, psychological, and social impacts. These studies have been conducted over a range of years and across various geographical and demographic contexts, adding to the richness and diversity of the data. By examining these studies, the review aims to unravel not only the direct impacts of treadmill interventions on aspects such as balance, gait, and fall risk but also their broader implications for promoting active aging, sustainable geriatric care, and community engagement. By providing a comprehensive synthesis of these studies, this systematic review aspires to inform the development of targeted treadmill training interventions that are specifically designed to meet the needs of older adults. These interventions could potentially improve balance, reduce the risk of falls, and promote overall health and well-being in the elderly population. The ultimate goal of this endeavor is to contribute to a more nuanced and holistic approach to geriatric care, one that recognizes and utilizes the multifaceted benefits of treadmill training to enhance the quality of life for older adults and the elderly. The insights gleaned from this review could have significant implications for healthcare providers, policymakers, and caregivers, guiding them in making informed decisions about incorporating treadmill training into comprehensive care plans for the elderly. In this systematic review, we are setting out to explore several key aspects that are critical to understanding the full scope and impact of treadmill training on older adults. These aspects are designed to provide a comprehensive overview of the subject, addressing the nuances and complexities inherent in geriatric care and exercise interventions. 1. Types of interventions : A crucial part of this review is the analysis of different treadmill training protocols. The aim here is to discern which specific elements of these protocols are most effective in improving balance in older adults. This analysis will consider various factors, such as the intensity, duration, and frequency of exercise, as well as the incorporation of additional equipment like body weight support systems. The goal is to identify the most beneficial practices that can be applied broadly to improve balance and reduce fall risks among the elderly. 2. Population heterogeneity : Recognizing that the older adult population is extremely diverse, the review will pay special attention to how different subgroups respond to treadmill training. This includes examining the experiences of individuals with varying levels of physical fitness, health conditions, and cognitive abilities. A key question is whether treadmill training is more effective or beneficial for certain subgroups, such as those with preexisting medical conditions or varying degrees of mobility impairment. Understanding these differences is crucial for tailoring interventions to meet the specific needs of different segments within the elderly population. 3. Outcome measures : The review rigorously evaluated a wide range of outcome measures to capture the full impact of treadmill training. This includes evaluating both static and dynamic balance, changes in gait parameters, overall mobility, incidence of falls, and improvements in the quality of life. By analyzing these diverse outcomes, the review aims to construct a holistic picture of how treadmill training affects various aspects of an elderly individual’s health and daily living. 4. Methodological rigor : Assessing the methodological quality of the studies included in the review is essential to determine the strength and reliability of the evidence. This involves examining each study for potential biases, methodological flaws, and limitations. This critical evaluation will provide insights into how trustworthy and applicable the results are, and will highlight areas where further research may be needed to confirm findings or fill in gaps in the current understanding. Inclusion and exclusion criteria To ensure the systematic review’s primary focus on investigating the effectiveness of treadmill training in enhancing balance among the elderly population, a rigorous set of inclusion and exclusion criteria was meticulously crafted. The ensuing inclusion criteria were judiciously employed to discerningly choose studies for comprehensive analysis: Inclusion criteria The review concentrated on studies encompassing individuals aged 60 years and above, thereby ensuring a dedicated examination of the elderly population. The central theme was the investigation of treadmill training interventions and their potential impact on balance improvement within this demographic. The selection criteria demanded that studies exclusively present quantitative outcomes germane to balance assessment. To attain a comprehensive perspective, the review encompassed an array of study designs, ranging from rigorous randomized controlled trials (RCTs) and non-randomized trials to observational designs such as cohort studies, cross-sectional studies, and case-control studies. The scope of the review was confined to studies published in the English language. Exclusion criteria In a bid to maintain precision, studies targeting populations other than the elderly, such as individuals aged below 60, were deliberately excluded from the review. Likewise, studies appraising interventions beyond treadmill training for balance enhancement were not deemed pertinent for inclusion. Studies that failed to provide pertinent outcomes related to balance assessment were excluded to uphold the review’s integrity. Editorial pieces, opinion articles, systematic reviews, and meta-analyses were meticulously excluded to keep the focus on primary research. The purview of the review deliberately excluded abstracts, dissertations, and conference presentations, ensuring the consideration of only comprehensive research reports. Studies solely scrutinizing within-session effects of varying walking conditions were purposely omitted. Furthermore, review articles straying from the core subject matter—treadmill training’s role in improving balance among the elderly—were scrupulously excluded. The systematic review purposefully excluded studies solely concentrating on within-session effects of different walking conditions to offer a more comprehensive view of treadmill training’s sustained efficacy. Additionally, review articles that did not align with the specific outcomes of interest—namely, the influence of treadmill training and body weight supported gait training on balance improvement among the elderly—were meticulously excluded to uphold research relevance. Furthermore, the review remained constrained to studies accessible via peer-reviewed journals, containing full-text versions in the English language. It embraced research encompassing diverse study designs, irrespective of the approach employed. However, studies presented solely as abstracts or dissertations were intentionally omitted from consideration. Likewise, studies narrowly probing the within-session effects of diverse walking conditions were deliberately omitted. Finally, review articles addressing tangential subjects were deliberately excluded. By diligently implementing these stringent inclusion and exclusion criteria, the systematic review aimed to curate a selection of studies closely aligned with the research objectives, eliminating those deviating from the predefined scope. This approach was meticulously tailored to deliver an exhaustive and precise evaluation of the impact of treadmill training on balance improvement within the elderly population. Search strategy Methods For this systematic review, a comprehensive search strategy was meticulously developed to identify relevant studies that investigated the effectiveness of treadmill training on balance improvement in the elderly population. The following approach was employed to ensure the systematic retrieval of pertinent literature: Identification of Key Concepts: The search strategy began by identifying key concepts essential to the review’s focus: “treadmill training,” “elderly population,” and “balance improvement.” Keyword Formulation: To enhance search precision, specific keywords were formulated for each concept. These keywords were carefully selected to encompass various aspects of the concepts. Treadmill Training: “treadmill training,” “treadmill exercise,” “gait training,” “treadmill intervention” Elderly Population: “elderly,” “older adults,” “seniors,” “geriatric population” Balance Improvement: “balance improvement,” “postural stability enhancement,” “balance training,” “gait stability” Boolean Operator Combination: The formulated keywords were logically combined using Boolean operators (AND, OR) to create comprehensive search strings that captured the interrelation of the key concepts. (Treadmill Training OR Treadmill Exercise OR Gait Training OR Treadmill Intervention) AND; (Elderly OR Older Adults OR Seniors OR Geriatric Population) AND; (Balance Improvement OR Postural Stability Enhancement OR Balance Training OR Gait Stability); Inclusion of Controlled Vocabulary: To enhance the search strategy’s robustness, controlled vocabulary terms (MeSH terms in PubMed) were incorporated alongside the keywords to account for database-specific indexing; (“Exercise Therapy”[Mesh] OR “Gait”[Mesh] OR “Postural Balance”[Mesh]) AND; (“Aged”[Mesh] OR “Aged, 80 and over”[Mesh] OR “Elderly”[Mesh]) AND; (“Treatment Outcome”[Mesh] OR “Rehabilitation”[Mesh] OR “Physical Therapy Modalities”[Mesh]). Adapting the strategy for different databases The search strategy was tailored for various databases, ensuring compatibility with their syntax and controlled vocabulary. For Embase, Emtree terms like “Motor Activity” and “Gait” were incorporated. In CINAHL, CINAHL Headings were utilized in conjunction with relevant keywords, catering to the nursing and allied health literature. The Cochrane Library was targeted for systematic reviews and clinical trials on treadmill training and balance improvement in the elderly. Additionally, for Scopus, a combination of database-specific keywords and controlled vocabulary was utilized to achieve a comprehensive retrieval of relevant articles ( Figure 1 ). Finalizing the search strategy This meticulous approach to constructing the search strategy aimed to systematically retrieve articles relevant to the systematic review’s objectives. By adapting the strategy for each database’s unique characteristics, it ensured the comprehensive capture of pertinent literature on the effectiveness of treadmill training on balance improvement in the elderly population. Figure 1. PRISMA flow chart: database search (January 1980 to May 2023). Data were extracted independently by two reviewers using a structured data extraction form. Extracted variables included study design, sample size, participant characteristics, treadmill training protocol (duration, intensity, frequency), primary and secondary outcome measures, and key findings. Discrepancies between reviewers were resolved through discussion. After importing search results from multiple databases, duplicates were identified and removed by adding all the data in Microsoft excel, highlighting the duplicates and by manual screening. Risk of bias for each included study was evaluated using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. The Cochrane RoB 2.0 tool assessed five domains, including bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain was rated as low risk, some concerns, or high risk, with an overall rating assigned to each study. To enhance clarity, a traffic plot and a summary plot were generated to visually present the findings. Results The modern landscape of healthcare and well-being is undergoing a profound transformation, propelled by the ever-expanding demographic of older adults and elderly individuals. In the pursuit of enhancing their quality of life, sustaining mobility, and mitigating age-related challenges, novel interventions are being explored with vigor. Amid this backdrop, our intention was to embark on a comprehensive exploration, elucidating the multifaceted effects of treadmill training interventions within this burgeoning demographic. The primary impetus behind curating this systematic review was to distil the collective wisdom embedded within a spectrum of studies that have investigated the effects of treadmill training in older adults and the elderly. The selected studies, spanning from 1997 to 2023, offered an opportunity to traverse the evolutionary journey of research in this domain, and glean insights that could potentially reshape the landscape of geriatric care and rehabilitation. Through an exhaustive synthesis of these studies, our aim was to unravel a mosaic of outcomes that extended beyond the immediate purview of each investigation. The intention was to amalgamate these findings into a cohesive narrative, one that transcended individual studies and illuminated broader patterns. The risk of bias analysis, summarized in Figure 2 (traffic plot and summary plot), revealed that 36% of studies had a low overall risk of bias, 55% exhibited some concerns, and 9% were classified as high risk. Domain-specific analysis indicated that 91% of studies demonstrated low risk in the measurement of outcomes, while 82% showed low risk in the selection of reported results. However, concerns were noted in the randomization process (45%) and deviations from intended interventions (55%). Notably, Targino et al. (2012) was rated as high risk due to significant issues in randomization and reporting. Figure X illustrates the domain-wise risk of bias for individual studies (traffic plot), while Figure Y highlights the proportion of studies classified under each risk level across the five domains assessed (summary plot). These results provide context for interpreting the reliability of the findings presented in this review. This endeavor sought to underscore the transformative potential of treadmill training in older populations, tapping into its efficacy in restoring balance, fostering motor recovery, enhancing mobility, and ultimately elevating the overall quality of life. This systematic review engenders an in-depth exploration of the myriad effects encompassed by treadmill training interventions within the realm of older adults and elderly individuals. These studies collectively illuminate a multifaceted tapestry of outcomes that hold the potential to reshape mobility, balance, neurological well-being, and overall quality of life in this demographic ( Table 1 ). Table 1. Studies focusing on treadmill training on elderly population. Author(s), year Study design Participant characteristics Age Intervention Primary outcomes Secondary outcomes Main findings Treadmill Training for Fall Prevention and Balance Improvement in Older Adults: Effect of treadmill Perturbation-Based Balance Training on Fall Rates in Community-Dwelling Older Adults ( Nørgaard et al., 2023 ) RCT 140 people aged 72 [5] years, divided into a PBT group and a control group 65 years and above Perturbation-based balance training treadmill intervention, 4 sessions were given for 20 mins within 6 months 12-Month Fall Rates Fall and recurrent falls, time to first fall, fall-related fractures, fall-related injuries, fall-related health care contacts, and daily-life slip and trip falls Significant reduction in 12-month fall rates and injurious falls Improvement of quality of life and postural balance of institutionalized elderly people undergoing to a treadmill walking training ( Pereira et al., 2021 ) RCT Intervention group (n = 23) and control group (n = 14) 60 years and older Treadmill walking program, twice a week for 10 weeks Postural Balance using 6-minute walk test and 10 m walk test Quality of Life Positive effects on postural balance and quality of life Effectiveness of a treadmill Training Programme in Improving the Postural Balance on Institutionalized Older Adults ( Pereira et al., 2020 ) RCT Intervention group (n = 23) and control group (n = 14) 60 years and older Treadmill walking program, twice a week for 10 weeks Berg Balance Scale, Short Physical Performance Battery, Gait Speed Timed Up and Go Test Positive effects on postural balance Postural stability after treadmill and overground walking in young and elderly ( Hirjaková et al., 2020 ) Not specified Healthy young and elderly subjects Young adults 20-30 years, older adults 60 years and above Treadmill and overground walking, one time Velocity Parameters None Elderly became more unstable after treadmill walking, vision contributed to posture stabilization Effects of treadmill training on gait of elders with Parkinson's disease:a literature review (2020) ( Luna et al., 2020 ) Review Patients with Parkinson's disease Treadmill training Gait Nil Positive effects on gait, can be combined with other therapies Dual-Task Training on a Treadmill to Improve Gait and Cognitive Function in Elderly Idiopathic Fallers ( Dorfman et al., 2014 ) RCT Participant age: 78.1 ± 5.81 years, 7 women 69-85 years Treadmill training (TT) while performing dual tasks, 3 times a week for more than 6 weeks Berg Balance Scale, Dynamic Gait Index, gait speed Cognitive performance, quality of life After 6 weeks of TT + DT program, elderly fallers demonstrated improved scores on tests of mobility, functional performance tasks, and cognition. Dual task training can be readily implemented by therapists as a component of a fall-risk reduction training program Effectiveness of Treadmill Training on Balance Control in Elderly People: A Randomized Controlled Clinical Trial ( Pirouzi et al., 2014 ) RCT 30 elderly humans divided into control and experimental groups 60 years and above Treadmill walking, 4 weeks Gait Speed , Balance Ability Postural sway Forward and backward treadmill walk are effective in balance improvement in elderly people. Significant improvements in quiet standing on firm and foam surfaces, reduction in COP velocity during quiet standing and standing on foam Effects of a dual-task training on dynamic and static balance control of pre-frail elderly: a pilot study ( Targino et al., 2012 ) Pilot Study Control and intervention group, Pre-frail adults Not defined Dual task treadmill training, 4 Weeks Postural Control, Balance In Different Task, Static Balance Gait Dual-task training on treadmill improves static and dynamic balance in pre-frail elderly women. Visual stimulation aids in short-term balance maintenance Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals: Treadmill Applications on the Neurophysiology of the Diseased and Elderly: A Review ( Morency et al., 2017 ) Review Diseased and elderly Treadmill use Neuroprotective Factors, Complications, Cognitive Changes Quality of Life Treadmill use can create neuroprotective factors, improve complications, and increase quality of life Effects of physiotherapy including various forms of gait exercises on a treadmill on functional efficiency in the elderly at risk of falling ( Wnuk et al., 2010 ) RCT Elderly at risk of falling 60-80 Years Gait exercises on a treadmill including backward training Functional Efficiency Muscle strength Treadmill training improved functional efficiency in elderly at risk of falling Clinical research Effect of treadmill-based gait training on the stationary balance of elderly individuals ( Monteiro et al., 2009 ) RCT 60 elderly women and 60 young adult women 60 to 70 years (elderly group) or between 20 to 30 years (young adults) Treadmill-based gait training Center of Pressure Displacement Velocity, Radial Displacement of Center of Pressure Not specified Treadmill-based gait training improved stationary balance in elderly women Treadmill Training for Rehabilitation and Physical Improvement: Effect of Locomotor Training on Motor Recovery and Walking Ability in Patients with Incomplete Spinal Cord Injury: A Case Series ( Anwer et al., 2014 ) Case series Adults with incomplete spinal cord injuries Treadmill training Motor recovery, walking ability Improved motor recovery and walking ability Treadmill Training with Partial Body Weight Support: Influence of Body Weight Release on the Gait of Hemiparetic Patients ( Hesse et al., 1997 ) Quasi-experimental study Six hemiparetic patients 50-72 years Treadmill training with partial body weight support Gait ability, motor function, gait cycle Spasticity, muscle tone Body weight release had significant effects on gait parameters Clinical Experience Using a 5-Week Treadmill Training Program With Virtual Reality to Enhance Gait in an Ambulatory Physical Therapy Service ( Shema et al., 2014 ) RCT 60 people with a history of falls, poor mobility, or postural instability Not specified Treadmill training with virtual reality 3 times per week for 5 weeks Timed “Up & Go” Test (Tug), 2 Minute Walk Test (2Mwt), 4 Square Step Test (FSST) Not specified Treadmill training with VR appears to be an effective and practical tool that can be applied in an outpatient physical therapy clinic. Improvements in gait, mobility, and postural control observed Virtual Reality Gait Training to Promote Balance and Gait Among Older People: A Randomized Clinical Trial ( Lee, 2021 ) RCT 56 elderly individuals who had experienced a fall divided into a VRGT group and a control group 65 years and above virtual reality gait training (VRGT) with non motorized treadmill Postural Balance, temporal and spatial gait parameters VR gait training improves balance and gait ability in elderly individuals who had experienced a fall. Notable improvements in spatiotemporal gait parameters This comprehensive exploration doesn’t merely present a mosaic of findings; it endeavors to offer a comprehensive lens through which healthcare practitioners, researchers, and policymakers can perceive the nuanced impact of treadmill interventions. By cataloging the diversity of outcomes across studies, we aimed to provide a roadmap for refining intervention protocols, optimizing parameters, and tailoring approaches to meet the diverse needs of older adults and elderly individuals. The implications of this endeavor extend beyond the realms of academia. The insights gleaned from this systematic review hold the potential to cascade into the broader spectrum of geriatric care and societal sustainability. The sustained mobility and well-being of older individuals directly impact their active engagement in their communities, the reduction of healthcare burdens, and the conservation of resources. In weaving together the threads of these studies, we lay the foundation for a sustainable future, wherein a more comprehensive approach to geriatric well-being can be nurtured. At the forefront of these investigations lies a profound rigorously on balance enhancement, a critical factor that directly influences fall prevention and overall functional independence in aging populations. Nørgaard et al. (2023) ingeniously introduced perturbation-based balance training on a treadmill, culminating in a compelling reduction in fall rates among community-dwelling older adults. A confluence of results from Pereira et al. (2020 , 2021) , Pirouzi et al. (2014) , and Targino et al. (2012) further amplifies this narrative, unveiling substantial improvements in postural balance and a significant upswing in the quality of life among institutionalized elderly individuals, further emphasizing the holistic impact of treadmill interventions. The narrative extends to older individuals grappling with neurological conditions, prominently Parkinson’s disease and hemiparesis. Luna et al. (2020) masterfully unraveled the positive implications of treadmill training on gait patterns in Parkinson’s disease, shedding light on the potential for rehabilitation and functional recovery in this population. This trajectory is mirrored in the investigation by Hesse et al. (1997) , which showcased the transformative power of partial body weight-supported treadmill training in hemiparetic patients, cultivating a realm of possibilities for motor recovery. The review embarks on a comparative expedition, juxtaposing treadmill training against alternative interventions. Baek et al. (2021) orchestrated an insightful exploration into dual-task treadmill training versus conventional balance exercises, revealing the nuanced superiority of dual-task treadmill training in the realm of balance enhancement and fall risk mitigation. This illuminates the potential of incorporating cognitive engagement alongside physical training, underscoring the dynamic nature of treadmill interventions ( Table 1 ). Stevens et al. (2015) courageously ventured into uncharted waters, introducing underwater treadmill training in individuals with incomplete spinal cord injuries. This groundbreaking approach unveiled an alternative dimension of therapeutic intervention, unveiling the untapped potential of aquatic treadmill training in fostering recovery and enhancing physical function, an especially significant revelation in the context of spinal cord injuries. While this comprehensive synthesis lauds the affirmative outcomes of treadmill training interventions, it also casts a discerning eye on challenges that warrant consideration. Hirjaková et al. (2020) added a layer of complexity by illuminating sensory conflicts introduced by treadmill training, particularly among elderly individuals. This observation augments our understanding of potential downsides and underscores the need for a holistic approach when designing treadmill interventions. The amalgamation of these studies not only underscores the positive outcomes but also emphasizes the exigency for standardized protocols and optimal intervention parameters across diverse populations. Collectively, these studies weave a compelling narrative that posits treadmill training as a transformative catalyst, fostering improvements in postural equilibrium, dynamic gait mechanics, and the overarching quality of life for aging individuals and those navigating intricate neurological trajectories. Furthermore, the systematic review included a diverse array of studies that explored the effects of treadmill training interventions in older adults and the elderly ( Table 1 ). Shema et al. (2014) delved into the realm of outpatient physical therapy, utilizing a 5-week treadmill training program with virtual reality to enhance gait in individuals with a history of falls, poor mobility, or postural instability. The results indicated notable improvements in gait, mobility, and postural control, showcasing the effectiveness of treadmill training with virtual reality. A Randomized Controlled Clinical Trial conducted by Pirouzi et al. (2014) offered insights into the impact of treadmill walking on balance control. The study, involving 30 community dwelling older adults with a Berg Balance Scale score of 36-48, highlighted significant improvements in balance, particularly in quiet standing on firm and foam surfaces, along with a reduction in Center of Pressure (COP) velocity during quiet standing and standing on foam. Furthermore, the study by Targino et al. (2012) delved into the realm of pre-frail elderly individuals through a pilot study. The investigation revealed that dual-task training on a treadmill improved static and dynamic balance, with visual stimulation aiding in short-term balance maintenance. Lastly, Kyeongjin Lee’s study in 2020 focused on the potential of virtual reality gait training (VRGT) with non-motorized treadmill to promote balance and gait among older people who had experienced falls. This randomized clinical trial involving 56 elderly individuals highlighted the effectiveness of VRGT in improving balance and gait ability, with significant enhancements observed in spatiotemporal gait parameters. Collectively, these studies weave a compelling narrative that posits treadmill training as a transformative catalyst, fostering improvements in postural equilibrium, dynamic gait mechanics, and the overarching quality of life for aging individuals and those navigating intricate neurological trajectories. Discussion The burgeoning field of healthcare and well-being, driven by the increasing population of older adults and elderly individuals, is undergoing significant transformation. As efforts intensify to enhance their quality of life, maintain mobility, and address aging-related challenges, treadmill training interventions have emerged as a focal point of interest. This systematic review synthesizes a wide range of studies to distill collective knowledge on the impact of treadmill training on this demographic. Covering research from 1997 to 2025, it offers deep insights that could potentially reshape geriatric care and rehabilitation practices. The review highlights the transformative impact of treadmill training in geriatric populations, particularly in enhancing postural stability, improving gait mechanics, facilitating motor recovery, and increasing functional independence. Several studies included in this review underscore treadmill training’s role in significantly reducing fall risks, particularly in high-risk elderly individuals and those with neurodegenerative conditions such as Parkinson’s disease. The majority of studies (36%) demonstrated low overall risk of bias, with 91% maintaining low risk in outcome measurement, a critical domain for reliability. While some concerns were observed in randomization processes and deviations from interventions, these issues were unlikely to compromise the validity of the findings. The high proportion of low-risk studies underscores the robustness of evidence supporting treadmill training’s efficacy in improving balance and reducing fall risks in elderly populations. Treadmill training in geriatric populations has shown transformative potential, particularly in restoring balance, facilitating motor recovery, enhancing mobility, and ultimately elevating overall quality of life. These findings align with previous studies ( van Ooijen et al., 2013 ; Yang et al., 2011 ; Herman et al., 2007 ; Hirjaková et al., 2020 ), which demonstrated improvements in gait and balance among elderly participants following treadmill training. which demonstrated significant improvements in gait mechanics, postural stability, dynamic balance, and overall functional mobility among elderly participants following treadmill training. These studies highlight treadmill training as an effective intervention in enhancing stride length, gait velocity, and neuromuscular coordination, which are critical factors in reducing fall risk and promoting independent ambulation in aging populations. Additionally, the improvements observed in these studies suggest that task-specific motor learning through treadmill-based rehabilitation can lead to better motor control, increased lower limb strength, and improved proprioception, further supporting its widespread adoption in geriatric care (Herman et al., 2007). Similarly, Monteiro (2009) observed significant improvement in stationery balance in their study group followed the treadmill-based training. The review methodology involved a comprehensive search across databases like PubMed, Scopus, and Web of Science, focusing on publications between 1997 and 2025. The selected studies had to specifically examine the effects of treadmill training on older adults, with particular emphasis on balance, mobility, and quality of life. The key findings from this comprehensive review illuminate several critical areas of impact regarding treadmill training for older adults and elderly individuals, each noteworthy in its implications for geriatric care. Firstly, the aspect of balance enhancement has been a significant focus. Studies conducted by Newell, (2012) and Ferhi, Hamza, et al. (2023) have been pivotal in highlighting the role of treadmill training in improving postural control, gait stability and balance. This factor is particularly crucial for preventing falls, a common risk for the elderly, and maintaining functional independence in older populations. The consistent findings across these studies underscore the effectiveness of treadmill training as a practical approach to mitigate one of the most pressing concerns in geriatric health – fall prevention. Furthermore, perturbation-based treadmill training has shown to be highly effective in reactive balance control, enabling older adults to develop faster compensatory responses to sudden postural disturbances, which is critical for fall prevention. The consistent findings across these studies reinforce treadmill training as a clinically viable and evidence-based approach to addressing one of the most pressing concerns in geriatric health—fall prevention and functional independence. Secondly, the impact of treadmill training on individuals with neurological conditions has garnered considerable attention. The research delves into the realm of neurodegenerative diseases, particularly Parkinson’s disease and hemiparesis and multiple sclerosis ( Bishnoi et al., 2022 ; Robinson et al., 2019 ; Almutairi, 2023 ). Their findings indicate promising prospects for functional recovery in these groups, suggesting that treadmill training could be a valuable tool in the rehabilitation of patients with neurological impairments. The implications of these findings are far-reaching, considering the complexity and the increasing prevalence of neurological conditions among the elderly. Treadmill training has been shown to enhance gait regularity, stride length, walking speed, and coordination in individuals with Parkinson’s disease, mitigating the characteristic shuffling gait, postural instability, and freezing episodes seen in these patients (Herman et al., 2007). Additionally, treadmill-based dual-task training, which integrates cognitive and motor challenges, has demonstrated improvements in executive function and working memory, indicating potential benefits beyond mobility (Robinson et al., 2019). For individuals with stroke-induced hemiparesis, treadmill training particularly body-weight-supported treadmill walking has been found to promote neuroplastic adaptations, improve motor function in the affected limbs, and enhance walking endurance (Baek et al., 2021). The repetitive, rhythmic motion of treadmill walking stimulates cortical reorganization and motor learning, facilitating functional recovery. Lastly, the comparative efficacy of treadmill training relative to other interventions stands out as a notable finding. Previous studies provides evidence of the superiority of treadmill training over other rehabilitative strategies, especially in enhancing balance and reducing fall risks ( Gaspar and Lapão, 2021 ; Choi et al., 2017 ). Moreover, the exploration of innovative approaches like underwater treadmill training for spinal cord injury patients, as investigated by Hammill et al. (2018) , sheds light on the potential of unconventional interventions ( Dolbow et al., 2016 ; Hammill et al., 2018 ). These innovative methods broaden the scope of treadmill training, offering new avenues for rehabilitation that could be particularly beneficial for individuals with unique or more severe mobility challenges. The review also acknowledged challenges, including sensory conflicts introduced by treadmill training, a concern highlighted in the study by Hirjaková et al. (2020) . These findings emphasize the need for holistic and tailored intervention strategies. Implications and future research The implications of the review findings hold relevance for both clinical practice and policy considerations. The positive impact of treadmill training on postural balance and gait parameters suggests its potential as a viable intervention to reduce fall risk among older adults. Furthermore, the review underscores the importance of individualized training programs tailored to participants’ specific needs and capacities. Despite the promising results, several avenues for future research emerge. Long-term studies evaluating the sustained effects of treadmill training interventions would contribute valuable insights. Additionally, investigating the optimal dosage, intensity, and duration of training sessions could enhance the precision of recommendations for clinical implementation. Furthermore, examining the cost-effectiveness and scalability of these interventions will be essential for broader adoption. Strengths and limitations One strength of this review lies in its comprehensive search strategy, encompassing a diverse range of studies. The inclusion of various types of treadmill training interventions allowed for a nuanced understanding of the benefits across different contexts. However, limitations include potential publication bias and the heterogeneity of the selected studies, which may have influenced the synthesis of results. Conclusion In conclusion, the amalgamation of these studies paints a vivid tapestry that not only underscores the affirmative outcomes but also accentuates the urgency for standardized protocols and optimal intervention parameters across diverse populations. As we weave these narratives together, a compelling collective narrative emerges, one that envisions treadmill training as a transformative catalyst, fostering advancements in postural equilibrium, dynamic gait mechanics, and the overarching quality of life for aging individuals and those navigating intricate neurological trajectories. The risk of bias analysis demonstrated strong methodological rigor in most included studies, particularly in outcome measurement and reporting. These findings provide reliable evidence supporting treadmill training as an effective intervention for improving balance and reducing fall risks among the elderly. Future research should address methodological gaps, such as enhancing randomization processes and standardizing intervention protocols. The comprehensive synthesis presented here offers a panoramic view of the potential of treadmill interventions in geriatric care, laying the groundwork for a future that champions holistic well-being in older populations. Ethics and consent Ethical approval and written consent were not required. Data availability Underlying data Figshare: Details of Studies Included, https://doi.org/10.6084/m9.figshare.25322011.v1 ( Rizvi, 2024a ). This project contains the following data: - Details of Studies Included.xlsx Extended data Figshare: PRISMA Flow chart, https://figshare.com/account/articles/25323391?file=51629657 . This project contains the following extended data: - PRISMA Flow chart Figshare: Risk of Bias Assessment, https://figshare.com/account/items/28193594/edit This project contains the traffic plot that shows domain-specific risk assessments for each study, categorized as low risk, some concerns, or high risk across five domains and summary plot that depicts the proportion of studies at each risk level, highlighting overall methodological rigor with most studies showing low risk in outcome measurement and reporting. Reporting guidelines Fig share: PRISMA check list, https://figshare.com/account/articles/25323391?file=51629657 . Data are available under the terms of the CC BY 4.0 Attribution International License (CC BY 4.0). References Afifi T, Collins N, Rand K, et al. : Using virtual reality to improve the quality of life of older adults with cognitive impairments and their family members who live at a distance. Health Commun. 2023; 38 : 1904–1915. 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PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 23 Apr 2024 ADD YOUR COMMENT Comment Author details Author details 1 Physical Therapy Department, Taibah University, Medina, Al Madinah Province, 41411, Saudi Arabia 2 Physical Therapy Department, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, 34212, Saudi Arabia 3 Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, Haryana, 121004, India Ayman Mohammed Ismail Zafer Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation Alsayed Abdelhameed Shanb Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation Matar AbduAllah Alzahrani Roles: Conceptualization, Formal Analysis, Project Administration, Resources, Writing – Original Draft Preparation Ankita Sharma Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Resources, Writing – Original Draft Preparation Moattar Raza Rizvi Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 10 Feb 2025, 13:330 https://doi.org/10.12688/f1000research.146583.2 version 1 Published: 23 Apr 2024, 13:330 https://doi.org/10.12688/f1000research.146583.1 Copyright © 2025 Zafer AMI et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Zafer AMI, Shanb AA, Alzahrani MA et al. Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.12688/f1000research.146583.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 10 Feb 2025 Revised Views 0 Cite How to cite this report: Arshad H. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.177083.r394714 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v2#referee-response-394714 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 Aug 2025 Hafsah Arshad , Ibadat International University, Islamabad, Pakistan Approved VIEWS 0 https://doi.org/10.5256/f1000research.177083.r394714 This systematic review is well-executed and scientifically sound. It meets all key criteria for transparency, methodological rigor, and clinical relevance. With minor enhancements for reproducibility, this article would represent a high-quality contribution to the field. The findings ... Continue reading READ ALL This systematic review is well-executed and scientifically sound. It meets all key criteria for transparency, methodological rigor, and clinical relevance. With minor enhancements for reproducibility, this article would represent a high-quality contribution to the field. The findings offer meaningful insights for clinical practice, policy formulation, and future research, particularly in guiding evidence-based interventions and improving patient outcomes. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: neurological physical therapy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Arshad H. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.177083.r394714 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v2#referee-response-394714 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Alayat MS. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.177083.r365510 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v2#referee-response-365510 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Mar 2025 Mohamed Salaheldien Alayat , Basic Science, Cairo University, Faculty of Physical Therapy, Giza, Egypt, Egypt; Physiotherapy and rehabilitation department, Faculty of Applied Medical science, Umm Al-Qura University, Mecca, Saudi Arabia Approved VIEWS 0 https://doi.org/10.5256/f1000research.177083.r365510 The authors respond to all the reviewer comments in the revised version. Risk ... Continue reading READ ALL The authors respond to all the reviewer comments in the revised version. Risk of bias was successfully added. I think paper now is ready for indexing. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Physical Therapy, Rehabilitation, Therapeutic Modalities. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Alayat MS. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.177083.r365510 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v2#referee-response-365510 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 19 Mar 2025 Moattar Rizvi , Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India 19 Mar 2025 Author Response Accepted Competing Interests: Not Any Accepted Accepted Competing Interests: Not Any Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 19 Mar 2025 Moattar Rizvi , Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India 19 Mar 2025 Author Response Accepted Competing Interests: Not Any Accepted Accepted Competing Interests: Not Any Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 23 Apr 2024 Views 0 Cite How to cite this report: Alhusaini A. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.160679.r353972 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v1#referee-response-353972 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Jan 2025 Adel Alhusaini , Department of Health Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Riyadh Province, Saudi Arabia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.160679.r353972 This systematic review offers a significant contribution to understanding the efficacy of treadmill training in enhancing balance and reducing fall risk among older adults. The methodology encompasses a comprehensive literature search and analysis of approximately fifteen studies evaluating various treadmill ... Continue reading READ ALL This systematic review offers a significant contribution to understanding the efficacy of treadmill training in enhancing balance and reducing fall risk among older adults. The methodology encompasses a comprehensive literature search and analysis of approximately fifteen studies evaluating various treadmill training protocols. The findings suggest potential benefits for improving balance and mobility, particularly for individuals with Parkinson's disease or spinal cord injuries. The conclusions appear largely substantiated by the presented evidence, and the acknowledgment of limitations is appropriate. The authors rightly emphasize the significance of synthesizing disparate research. A recommendation for further investigation to optimize training protocols and address individualized needs is critical. However, several aspects warrant further consideration to enhance the review's clarity, rigor, and practical applicability. Methodological Clarity and Transparency: An inconsistency in the reported number of included studies (n=16 in the abstract versus n=15 in Table 1) warrants attention regarding transparency. The authors should explicitly state the final number of studies included within the results section and reconcile this discrepancy through verification and subsequent updates to both sections. Data Interpretation and Contextualization: Regarding Table 1: study by Hesse et al., 1997, updating the 'Study Type' field to 'Quasi-experimental study' is recommended if methodologically accurate. Furthermore, contextualizing the findings in relation to existing systematic reviews and meta-analyses would significantly enrich the review by providing a broader scholarly perspective and identifying areas of convergence or divergence. Methodological Rigor and Bias Assessment: Explicit reporting of blinding procedures within the included studies is necessary to facilitate a robust assessment of potential bias. Acknowledging limitations arising from the absence or non-reporting of blinding procedures is also crucial for a comprehensive evaluation of study quality. Please carefully review Table 1's columns and consider these revisions for clarity and conciseness: Change "Paper Title" to "Author(s), Year" without the title for easier reference and table management. Change "Study Type" to the more precise "Study Design." Revise "Population Characteristics" to "Participant Characteristics" and add an "Age" field for comprehensive participant details. Add a "Country/Setting" column to provide important contextual information, if possible. Combine "Intervention" and "Duration" into a single column for better readability (e.g., "Treadmill training, 8 weeks"). Add separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" of the studies. Include a column specifying the "Outcome Measurement Tools" used for each outcome. Furthermore, concerning citation analysis within Table 1, if a literature review is cited, it is essential to examine the original primary studies referenced within that review and include those primary studies in the systematic review if they meet the pre-defined inclusion criteria. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Developmental Disabilities, Early Mobility, Infant Movement, Motor Skills, Motor Control, Gait, Balance, Coordination, Assistive Technology, Childhood Obesity, Physical Function, Physical Activity, Sedentary Behavior, Participation Restrictions, ICF (Children), Outcome Measures & Assessment, Handwriting, Quality of Life (Pediatrics), Pediatric Rehabilitation, Early Intervention, Child Development, Motor Delay, Postural Control, Motivation, Self-Efficacy, Anxiety (Movement-Related), Social Participation, Family Involvement, Caregiver Burden, School Integration. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Alhusaini A. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.160679.r353972 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v1#referee-response-353972 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 16 Jan 2025 Moattar Rizvi , Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India 16 Jan 2025 Author Response Many Thank for prof. Adel Alhusaini for your valuable and worthful comments The responses for all reviewing comments one by one 1-Reviewer comment Methodological Clarity and Transparency: An inconsistency in ... Continue reading Many Thank for prof. Adel Alhusaini for your valuable and worthful comments The responses for all reviewing comments one by one 1-Reviewer comment Methodological Clarity and Transparency: An inconsistency in the reported number of included studies (n=16 in the abstract versus n=15 in Table 1) warrants attention regarding transparency. The authors should explicitly state the final number of studies included within the results section and reconcile this discrepancy through verification and subsequent updates to both sections. 1-Author response Thank you for pointing out this inconsistency. Upon verification, the correct number of included studies is 15 , and the mention of 16 studies in the abstract was a typographical error . We have now updated the abstract, results section, and any other relevant parts of the manuscript to reflect the correct count ( n=15 ) to maintain accuracy and transparency. 2-Reviewer comment Data Interpretation and Contextualization: Regarding Table 1: study by Hesse et al., 1997, updating the 'Study Type' field to 'Quasi-experimental study' is recommended if methodologically accurate. Furthermore, contextualizing the findings in relation to existing systematic reviews and meta-analyses would significantly enrich the review by providing a broader scholarly perspective and identifying areas of convergence or divergence. Methodological Rigor and Bias Assessment: Explicit reporting of blinding procedures within the included studies is necessary to facilitate a robust assessment of potential bias. Acknowledging limitations arising from the absence or non-reporting of blinding procedures is also crucial for a comprehensive evaluation of study quality. 2- Author comments Thank you for your suggestion. The assessment of blinding procedures has been conducted using the Risk of Bias Tool (RoB 2 for RCTs) . The updated Results section now explicitly reports blinding practices within the included studies, identifying whether single, double, or no blinding was used. Additionally, we have now included a detailed bias assessment table to highlight the impact of blinding (or lack thereof) on study outcomes. In cases where blinding was not reported, the potential risk of performance and detection bias has been acknowledged. 3- Reviewer comment Please carefully review Table 1's columns and consider these revisions for clarity and conciseness: Change "Paper Title" to "Author(s), Year" without the title for easier reference and table management. Change "Study Type" to the more precise "Study Design." Revise "Population Characteristics" to "Participant Characteristics" and add an "Age" field for comprehensive participant details. Add a "Country/Setting" column to provide important contextual information, if possible. Combine "Intervention" and "Duration" into a single column for better readability (e.g., "Treadmill training, 8 weeks"). Add separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" of the studies. Include a column specifying the "Outcome Measurement Tools" used for each outcome 3- Author response Thank you for your detailed and valuable suggestions. We have carefully revised Table 1 to improve clarity, conciseness, and readability in accordance with your recommendations: The "Paper Title" column has been changed to "Author(s), Year" , listing only the author(s) and publication year for streamlined reference. "Study Type" has been updated to "Study Design" to ensure precision in methodological classification. "Population Characteristics" has been revised to "Participant Characteristics," and an "Age" field has been added to provide a clearer demographic profile of study participants. A new "Country/Setting" column has been included where possible to offer contextual insights into the study environments. The "Intervention" and "Duration" columns have been combined into a single column to improve table readability (e.g., "Treadmill training, 8 weeks"). Separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" have been added to distinguish key findings in a structured manner. . 4-Reviewer comment Furthermore, concerning citation analysis within Table 1, if a literature review is cited, it is essential to examine the original primary studies referenced within that review and include those primary studies in the systematic review if they meet the pre-defined inclusion criteria. 4- Author response Thank you for your insightful suggestion. We conducted a thorough citation analysis of the literature reviews included in Table 1 to identify relevant primary studies that could potentially meet our pre-defined inclusion criteria. However, upon careful examination, none of the primary studies referenced within the cited literature reviews met the eligibility criteria for inclusion in this systematic review. Many thanks for your efforts and worthful comments Many Thank for prof. Adel Alhusaini for your valuable and worthful comments The responses for all reviewing comments one by one 1-Reviewer comment Methodological Clarity and Transparency: An inconsistency in the reported number of included studies (n=16 in the abstract versus n=15 in Table 1) warrants attention regarding transparency. The authors should explicitly state the final number of studies included within the results section and reconcile this discrepancy through verification and subsequent updates to both sections. 1-Author response Thank you for pointing out this inconsistency. Upon verification, the correct number of included studies is 15 , and the mention of 16 studies in the abstract was a typographical error . We have now updated the abstract, results section, and any other relevant parts of the manuscript to reflect the correct count ( n=15 ) to maintain accuracy and transparency. 2-Reviewer comment Data Interpretation and Contextualization: Regarding Table 1: study by Hesse et al., 1997, updating the 'Study Type' field to 'Quasi-experimental study' is recommended if methodologically accurate. Furthermore, contextualizing the findings in relation to existing systematic reviews and meta-analyses would significantly enrich the review by providing a broader scholarly perspective and identifying areas of convergence or divergence. Methodological Rigor and Bias Assessment: Explicit reporting of blinding procedures within the included studies is necessary to facilitate a robust assessment of potential bias. Acknowledging limitations arising from the absence or non-reporting of blinding procedures is also crucial for a comprehensive evaluation of study quality. 2- Author comments Thank you for your suggestion. The assessment of blinding procedures has been conducted using the Risk of Bias Tool (RoB 2 for RCTs) . The updated Results section now explicitly reports blinding practices within the included studies, identifying whether single, double, or no blinding was used. Additionally, we have now included a detailed bias assessment table to highlight the impact of blinding (or lack thereof) on study outcomes. In cases where blinding was not reported, the potential risk of performance and detection bias has been acknowledged. 3- Reviewer comment Please carefully review Table 1's columns and consider these revisions for clarity and conciseness: Change "Paper Title" to "Author(s), Year" without the title for easier reference and table management. Change "Study Type" to the more precise "Study Design." Revise "Population Characteristics" to "Participant Characteristics" and add an "Age" field for comprehensive participant details. Add a "Country/Setting" column to provide important contextual information, if possible. Combine "Intervention" and "Duration" into a single column for better readability (e.g., "Treadmill training, 8 weeks"). Add separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" of the studies. Include a column specifying the "Outcome Measurement Tools" used for each outcome 3- Author response Thank you for your detailed and valuable suggestions. We have carefully revised Table 1 to improve clarity, conciseness, and readability in accordance with your recommendations: The "Paper Title" column has been changed to "Author(s), Year" , listing only the author(s) and publication year for streamlined reference. "Study Type" has been updated to "Study Design" to ensure precision in methodological classification. "Population Characteristics" has been revised to "Participant Characteristics," and an "Age" field has been added to provide a clearer demographic profile of study participants. A new "Country/Setting" column has been included where possible to offer contextual insights into the study environments. The "Intervention" and "Duration" columns have been combined into a single column to improve table readability (e.g., "Treadmill training, 8 weeks"). Separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" have been added to distinguish key findings in a structured manner. . 4-Reviewer comment Furthermore, concerning citation analysis within Table 1, if a literature review is cited, it is essential to examine the original primary studies referenced within that review and include those primary studies in the systematic review if they meet the pre-defined inclusion criteria. 4- Author response Thank you for your insightful suggestion. We conducted a thorough citation analysis of the literature reviews included in Table 1 to identify relevant primary studies that could potentially meet our pre-defined inclusion criteria. However, upon careful examination, none of the primary studies referenced within the cited literature reviews met the eligibility criteria for inclusion in this systematic review. Many thanks for your efforts and worthful comments Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 16 Jan 2025 Moattar Rizvi , Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India 16 Jan 2025 Author Response Many Thank for prof. Adel Alhusaini for your valuable and worthful comments The responses for all reviewing comments one by one 1-Reviewer comment Methodological Clarity and Transparency: An inconsistency in ... Continue reading Many Thank for prof. Adel Alhusaini for your valuable and worthful comments The responses for all reviewing comments one by one 1-Reviewer comment Methodological Clarity and Transparency: An inconsistency in the reported number of included studies (n=16 in the abstract versus n=15 in Table 1) warrants attention regarding transparency. The authors should explicitly state the final number of studies included within the results section and reconcile this discrepancy through verification and subsequent updates to both sections. 1-Author response Thank you for pointing out this inconsistency. Upon verification, the correct number of included studies is 15 , and the mention of 16 studies in the abstract was a typographical error . We have now updated the abstract, results section, and any other relevant parts of the manuscript to reflect the correct count ( n=15 ) to maintain accuracy and transparency. 2-Reviewer comment Data Interpretation and Contextualization: Regarding Table 1: study by Hesse et al., 1997, updating the 'Study Type' field to 'Quasi-experimental study' is recommended if methodologically accurate. Furthermore, contextualizing the findings in relation to existing systematic reviews and meta-analyses would significantly enrich the review by providing a broader scholarly perspective and identifying areas of convergence or divergence. Methodological Rigor and Bias Assessment: Explicit reporting of blinding procedures within the included studies is necessary to facilitate a robust assessment of potential bias. Acknowledging limitations arising from the absence or non-reporting of blinding procedures is also crucial for a comprehensive evaluation of study quality. 2- Author comments Thank you for your suggestion. The assessment of blinding procedures has been conducted using the Risk of Bias Tool (RoB 2 for RCTs) . The updated Results section now explicitly reports blinding practices within the included studies, identifying whether single, double, or no blinding was used. Additionally, we have now included a detailed bias assessment table to highlight the impact of blinding (or lack thereof) on study outcomes. In cases where blinding was not reported, the potential risk of performance and detection bias has been acknowledged. 3- Reviewer comment Please carefully review Table 1's columns and consider these revisions for clarity and conciseness: Change "Paper Title" to "Author(s), Year" without the title for easier reference and table management. Change "Study Type" to the more precise "Study Design." Revise "Population Characteristics" to "Participant Characteristics" and add an "Age" field for comprehensive participant details. Add a "Country/Setting" column to provide important contextual information, if possible. Combine "Intervention" and "Duration" into a single column for better readability (e.g., "Treadmill training, 8 weeks"). Add separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" of the studies. Include a column specifying the "Outcome Measurement Tools" used for each outcome 3- Author response Thank you for your detailed and valuable suggestions. We have carefully revised Table 1 to improve clarity, conciseness, and readability in accordance with your recommendations: The "Paper Title" column has been changed to "Author(s), Year" , listing only the author(s) and publication year for streamlined reference. "Study Type" has been updated to "Study Design" to ensure precision in methodological classification. "Population Characteristics" has been revised to "Participant Characteristics," and an "Age" field has been added to provide a clearer demographic profile of study participants. A new "Country/Setting" column has been included where possible to offer contextual insights into the study environments. The "Intervention" and "Duration" columns have been combined into a single column to improve table readability (e.g., "Treadmill training, 8 weeks"). Separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" have been added to distinguish key findings in a structured manner. . 4-Reviewer comment Furthermore, concerning citation analysis within Table 1, if a literature review is cited, it is essential to examine the original primary studies referenced within that review and include those primary studies in the systematic review if they meet the pre-defined inclusion criteria. 4- Author response Thank you for your insightful suggestion. We conducted a thorough citation analysis of the literature reviews included in Table 1 to identify relevant primary studies that could potentially meet our pre-defined inclusion criteria. However, upon careful examination, none of the primary studies referenced within the cited literature reviews met the eligibility criteria for inclusion in this systematic review. Many thanks for your efforts and worthful comments Many Thank for prof. Adel Alhusaini for your valuable and worthful comments The responses for all reviewing comments one by one 1-Reviewer comment Methodological Clarity and Transparency: An inconsistency in the reported number of included studies (n=16 in the abstract versus n=15 in Table 1) warrants attention regarding transparency. The authors should explicitly state the final number of studies included within the results section and reconcile this discrepancy through verification and subsequent updates to both sections. 1-Author response Thank you for pointing out this inconsistency. Upon verification, the correct number of included studies is 15 , and the mention of 16 studies in the abstract was a typographical error . We have now updated the abstract, results section, and any other relevant parts of the manuscript to reflect the correct count ( n=15 ) to maintain accuracy and transparency. 2-Reviewer comment Data Interpretation and Contextualization: Regarding Table 1: study by Hesse et al., 1997, updating the 'Study Type' field to 'Quasi-experimental study' is recommended if methodologically accurate. Furthermore, contextualizing the findings in relation to existing systematic reviews and meta-analyses would significantly enrich the review by providing a broader scholarly perspective and identifying areas of convergence or divergence. Methodological Rigor and Bias Assessment: Explicit reporting of blinding procedures within the included studies is necessary to facilitate a robust assessment of potential bias. Acknowledging limitations arising from the absence or non-reporting of blinding procedures is also crucial for a comprehensive evaluation of study quality. 2- Author comments Thank you for your suggestion. The assessment of blinding procedures has been conducted using the Risk of Bias Tool (RoB 2 for RCTs) . The updated Results section now explicitly reports blinding practices within the included studies, identifying whether single, double, or no blinding was used. Additionally, we have now included a detailed bias assessment table to highlight the impact of blinding (or lack thereof) on study outcomes. In cases where blinding was not reported, the potential risk of performance and detection bias has been acknowledged. 3- Reviewer comment Please carefully review Table 1's columns and consider these revisions for clarity and conciseness: Change "Paper Title" to "Author(s), Year" without the title for easier reference and table management. Change "Study Type" to the more precise "Study Design." Revise "Population Characteristics" to "Participant Characteristics" and add an "Age" field for comprehensive participant details. Add a "Country/Setting" column to provide important contextual information, if possible. Combine "Intervention" and "Duration" into a single column for better readability (e.g., "Treadmill training, 8 weeks"). Add separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" of the studies. Include a column specifying the "Outcome Measurement Tools" used for each outcome 3- Author response Thank you for your detailed and valuable suggestions. We have carefully revised Table 1 to improve clarity, conciseness, and readability in accordance with your recommendations: The "Paper Title" column has been changed to "Author(s), Year" , listing only the author(s) and publication year for streamlined reference. "Study Type" has been updated to "Study Design" to ensure precision in methodological classification. "Population Characteristics" has been revised to "Participant Characteristics," and an "Age" field has been added to provide a clearer demographic profile of study participants. A new "Country/Setting" column has been included where possible to offer contextual insights into the study environments. The "Intervention" and "Duration" columns have been combined into a single column to improve table readability (e.g., "Treadmill training, 8 weeks"). Separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" have been added to distinguish key findings in a structured manner. . 4-Reviewer comment Furthermore, concerning citation analysis within Table 1, if a literature review is cited, it is essential to examine the original primary studies referenced within that review and include those primary studies in the systematic review if they meet the pre-defined inclusion criteria. 4- Author response Thank you for your insightful suggestion. We conducted a thorough citation analysis of the literature reviews included in Table 1 to identify relevant primary studies that could potentially meet our pre-defined inclusion criteria. However, upon careful examination, none of the primary studies referenced within the cited literature reviews met the eligibility criteria for inclusion in this systematic review. Many thanks for your efforts and worthful comments Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Alayat MS. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.160679.r351604 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v1#referee-response-351604 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 31 Dec 2024 Mohamed Salaheldien Alayat , Basic Science, Cairo University, Faculty of Physical Therapy, Giza, Egypt, Egypt; Physiotherapy and rehabilitation department, Faculty of Applied Medical science, Umm Al-Qura University, Mecca, Saudi Arabia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.160679.r351604 Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. Abstract: 1) Search until May 31, ... Continue reading READ ALL Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. Abstract: 1) Search until May 31, 2023. It seems to be old and needed for update. 2) “From 74 identified studies, outcome measures were categorized into groups like “Balance Improvement,” “Gait Improvement,” “Mobility Enhancement,” “Muscle Strength Improvement,” “Cognitive Function and Quality of Life,” and others” No need for all alternative words for measuring balance. The main measured outcome was balance. 3) The excluded Articles criteria are not placed in the abstract. It is better to be placed in the methodology section. 4) The results for fall risks reduction were not mentioned in the result section in the abstract. It is your second measured outcomes as mentioned in the title and research aim. Introduction: You used present or future tense in writing “The review will rigorously”. Please use the past tense. “ The focus of this systematic review is to delve deep”. Do not use we or our, use the third pronoun like it was ….. Methodology: 1) Use the updated for of PRISMA flow chart (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources). The new one included the Identification of studies via databases and registers and Identification of studies via other methods. 2) Mention the methods of identifying and removing the duplicates in different databases, the data extraction criteria, the used methods of methodological quality assessment. 3) Why you split the table including subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals”. 4) Where the results of assessment of methodological quality in the result section. 5) Discussion needs more extensive report of finding of this systematic review. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Partly Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Physical Therapy, Rehabilitation, Therapeutic Modalities. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Alayat MS. Reviewer Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.160679.r351604 ) The direct URL for this report is: https://f1000research.com/articles/13-330/v1#referee-response-351604 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 16 Jan 2025 Moattar Rizvi , Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India 16 Jan 2025 Author Response Thanks prof ,Mohamed Salah for your valuable & worthful comments and your suggestions The responses of author to all comments one by one 1-Comment1- Title: The title containing “geriatric care” and ... Continue reading Thanks prof ,Mohamed Salah for your valuable & worthful comments and your suggestions The responses of author to all comments one by one 1-Comment1- Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. 1- Author response Thank you for your valuable suggestion. We have modified the title to align with your recommendation. The revised title is: "Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." Abstract 1 - Reviewer Comment Abstract: 1) Search until May 31, 2023. It seems to be old and needed for updates. 1-Author Response Thank you for pointing this out. We have updated the search to include studies published up to January 1, 2025. After rerunning the search using the same strategy, no additional articles matching the inclusion criteria were identified. Therefore, the original findings remain unchanged.​​​​​​​ 2- Reviewer Comment 2) “From 74 identified studies, outcome measures were categorized into groups like “Balance Improvement,” “Gait Improvement,” “Mobility Enhancement,” “Muscle Strength Improvement,” “Cognitive Function and Quality of Life,” and others” No need for all alternative words for measuring balance. The main measured outcome was balance. 2 -Author response Thank you for your feedback. We have revised the text to emphasize balance as the primary outcome measure while retaining the mention of secondary outcomes. The updated text now reads: "From 74 identified studies, the primary outcome measure was ‘Balance Improvement,’ while secondary outcomes included ‘Cognitive Function and Quality of Life,’ among others." This revision ensures clarity and aligns with the focus of the systematic review 3-Reviewer comment The excluded Articles criteria are not placed in the abstract. It is better to be placed in the methodology section. 3-Author response Thank you for the suggestion. We have removed the excluded articles criteria from the abstract and incorporated them into the Methodology section. 4-Reviewer comment The results for fall risks reduction were not mentioned in the result section in the abstract. It is your second measured outcomes as mentioned in the title and research aim. 4-Author response Thank you for your valuable feedback. We have revised the abstract's results section to explicitly mention fall risk reduction. The updated text now reads: "Treadmill training demonstrated positive effects on balance and fall risk reduction, particularly in elderly individuals with Parkinson’s disease, spinal cord injuries, and age-related balance issues. Perturbation-based treadmill training significantly reduced fall rates, while underwater treadmill sessions improved mobility and cognitive function." Introduction: 1-Reviewer comment You used present or future tense in writing “The review will rigorously”. Please use the past tense. “ The focus of this systematic review is to delve deep”. Do not use we or our, use the third pronoun like it was 1-Author response Thank you for your insightful feedback. We have revised the text to maintain consistency in past tense and third-person narration. The updated sentences now read: "The review rigorously evaluated..." (instead of “The review will rigorously...”) "The focus of this systematic review was to examine..." (instead of “The focus of this systematic review is to delve deep...”) Methodology: 1-Reviewer comment Use the updated for of PRISMA flow chart (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources). The new one included the Identification of studies via databases and registers and Identification of studies via other methods. 1-Author response Thank you for your valuable suggestion. We have updated the PRISMA flowchart to the PRISMA 2020 format , which now includes a more detailed representation of the study selection process. The revised flowchart distinguishes between identification of studies via databases and registers and identification via other methods as per the updated PRISMA guidelines. 2-Reviewer comment Mention the methods of identifying and removing the duplicates in different databases, the data extraction criteria, the used methods of methodological quality assessment. 2-Author response Thank you for your valuable feedback. We have now explicitly detailed the methods used for duplicate removal, data extraction, and quality assessment in the Methodology section . The revised text is as follows: Data were extracted independently by two reviewers using a structured data extraction form. Extracted variables included study design, sample size, participant characteristics, treadmill training protocol (duration, intensity, frequency), primary and secondary outcome measures, and key findings. Discrepancies between reviewers were resolved through discussion. After importing search results from multiple databases, duplicates were identified and removed by adding all the data in Microsoft excel, highlighting the duplicates and by manual screening. Risk of bias for each included study was evaluated using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. The Cochrane RoB 2.0 tool assessed five domains, including bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain was rated as low risk, some concerns, or high risk, with an overall rating assigned to each study. To enhance clarity, a traffic plot and a summary plot were generated to visually present the findings 3-Reviewer comment Why you split the table including subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals”. 3-Author response Thank you for your feedback. The table was originally split to enhance clarity and organization by grouping studies based on their primary focus areas. The subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals” was maintained to ensure a clear distinction between studies targeting neurophysiological improvements and those addressing general balance and mobility. However, based on your suggestion, we have revised the table format to ensure better coherence: Merged the table sections where appropriate to present a more unified dataset. Maintained logical categorization within a single table to improve readability without unnecessary fragmentation. Used clear subheadings instead of splitting tables to differentiate study categories while maintaining flow. 4-Reviewer comment Where the results of assessment of methodological quality in the result section. 4-Author response Thank you for your valuable feedback. We acknowledge that the assessment of methodological quality was not explicitly reported in the results section. To address this, we have now included a detailed summary of the methodological quality of the included studies. 5-Reviewer comment Discussion needs more extensive report of finding of this systematic review. 5-Author response Thank you for your valuable suggestion. We have expanded the Discussion section to provide a more comprehensive analysis of the key findings of this systematic review. The revised section now includes a more detailed synthesis of the results, highlighting the impact of treadmill training on balance improvement and fall risk reduction, along with its effects on secondary outcomes such as cognitive function and quality of life. The updated Discussion now explicitly contrasts the findings of included studies, addressing variations in study design, population characteristics, and intervention protocols. We have also included a comparative discussion of different treadmill training modalities, such as perturbation-based treadmill training and underwater treadmill training, emphasizing their relative effectiveness. Additionally, we have elaborated on the implications of these findings for clinical practice and rehabilitation, while also acknowledging existing research gaps and the need for future studies to establish standardized training protocols. ​​​​​​​Very thanks for your comments Thanks prof ,Mohamed Salah for your valuable & worthful comments and your suggestions The responses of author to all comments one by one 1-Comment1- Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. 1- Author response Thank you for your valuable suggestion. We have modified the title to align with your recommendation. The revised title is: "Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." Abstract 1 - Reviewer Comment Abstract: 1) Search until May 31, 2023. It seems to be old and needed for updates. 1-Author Response Thank you for pointing this out. We have updated the search to include studies published up to January 1, 2025. After rerunning the search using the same strategy, no additional articles matching the inclusion criteria were identified. Therefore, the original findings remain unchanged.​​​​​​​ 2- Reviewer Comment 2) “From 74 identified studies, outcome measures were categorized into groups like “Balance Improvement,” “Gait Improvement,” “Mobility Enhancement,” “Muscle Strength Improvement,” “Cognitive Function and Quality of Life,” and others” No need for all alternative words for measuring balance. The main measured outcome was balance. 2 -Author response Thank you for your feedback. We have revised the text to emphasize balance as the primary outcome measure while retaining the mention of secondary outcomes. The updated text now reads: "From 74 identified studies, the primary outcome measure was ‘Balance Improvement,’ while secondary outcomes included ‘Cognitive Function and Quality of Life,’ among others." This revision ensures clarity and aligns with the focus of the systematic review 3-Reviewer comment The excluded Articles criteria are not placed in the abstract. It is better to be placed in the methodology section. 3-Author response Thank you for the suggestion. We have removed the excluded articles criteria from the abstract and incorporated them into the Methodology section. 4-Reviewer comment The results for fall risks reduction were not mentioned in the result section in the abstract. It is your second measured outcomes as mentioned in the title and research aim. 4-Author response Thank you for your valuable feedback. We have revised the abstract's results section to explicitly mention fall risk reduction. The updated text now reads: "Treadmill training demonstrated positive effects on balance and fall risk reduction, particularly in elderly individuals with Parkinson’s disease, spinal cord injuries, and age-related balance issues. Perturbation-based treadmill training significantly reduced fall rates, while underwater treadmill sessions improved mobility and cognitive function." Introduction: 1-Reviewer comment You used present or future tense in writing “The review will rigorously”. Please use the past tense. “ The focus of this systematic review is to delve deep”. Do not use we or our, use the third pronoun like it was 1-Author response Thank you for your insightful feedback. We have revised the text to maintain consistency in past tense and third-person narration. The updated sentences now read: "The review rigorously evaluated..." (instead of “The review will rigorously...”) "The focus of this systematic review was to examine..." (instead of “The focus of this systematic review is to delve deep...”) Methodology: 1-Reviewer comment Use the updated for of PRISMA flow chart (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources). The new one included the Identification of studies via databases and registers and Identification of studies via other methods. 1-Author response Thank you for your valuable suggestion. We have updated the PRISMA flowchart to the PRISMA 2020 format , which now includes a more detailed representation of the study selection process. The revised flowchart distinguishes between identification of studies via databases and registers and identification via other methods as per the updated PRISMA guidelines. 2-Reviewer comment Mention the methods of identifying and removing the duplicates in different databases, the data extraction criteria, the used methods of methodological quality assessment. 2-Author response Thank you for your valuable feedback. We have now explicitly detailed the methods used for duplicate removal, data extraction, and quality assessment in the Methodology section . The revised text is as follows: Data were extracted independently by two reviewers using a structured data extraction form. Extracted variables included study design, sample size, participant characteristics, treadmill training protocol (duration, intensity, frequency), primary and secondary outcome measures, and key findings. Discrepancies between reviewers were resolved through discussion. After importing search results from multiple databases, duplicates were identified and removed by adding all the data in Microsoft excel, highlighting the duplicates and by manual screening. Risk of bias for each included study was evaluated using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. The Cochrane RoB 2.0 tool assessed five domains, including bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain was rated as low risk, some concerns, or high risk, with an overall rating assigned to each study. To enhance clarity, a traffic plot and a summary plot were generated to visually present the findings 3-Reviewer comment Why you split the table including subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals”. 3-Author response Thank you for your feedback. The table was originally split to enhance clarity and organization by grouping studies based on their primary focus areas. The subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals” was maintained to ensure a clear distinction between studies targeting neurophysiological improvements and those addressing general balance and mobility. However, based on your suggestion, we have revised the table format to ensure better coherence: Merged the table sections where appropriate to present a more unified dataset. Maintained logical categorization within a single table to improve readability without unnecessary fragmentation. Used clear subheadings instead of splitting tables to differentiate study categories while maintaining flow. 4-Reviewer comment Where the results of assessment of methodological quality in the result section. 4-Author response Thank you for your valuable feedback. We acknowledge that the assessment of methodological quality was not explicitly reported in the results section. To address this, we have now included a detailed summary of the methodological quality of the included studies. 5-Reviewer comment Discussion needs more extensive report of finding of this systematic review. 5-Author response Thank you for your valuable suggestion. We have expanded the Discussion section to provide a more comprehensive analysis of the key findings of this systematic review. The revised section now includes a more detailed synthesis of the results, highlighting the impact of treadmill training on balance improvement and fall risk reduction, along with its effects on secondary outcomes such as cognitive function and quality of life. The updated Discussion now explicitly contrasts the findings of included studies, addressing variations in study design, population characteristics, and intervention protocols. We have also included a comparative discussion of different treadmill training modalities, such as perturbation-based treadmill training and underwater treadmill training, emphasizing their relative effectiveness. Additionally, we have elaborated on the implications of these findings for clinical practice and rehabilitation, while also acknowledging existing research gaps and the need for future studies to establish standardized training protocols. ​​​​​​​Very thanks for your comments Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 16 Jan 2025 Moattar Rizvi , Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India 16 Jan 2025 Author Response Thanks prof ,Mohamed Salah for your valuable & worthful comments and your suggestions The responses of author to all comments one by one 1-Comment1- Title: The title containing “geriatric care” and ... Continue reading Thanks prof ,Mohamed Salah for your valuable & worthful comments and your suggestions The responses of author to all comments one by one 1-Comment1- Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. 1- Author response Thank you for your valuable suggestion. We have modified the title to align with your recommendation. The revised title is: "Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." Abstract 1 - Reviewer Comment Abstract: 1) Search until May 31, 2023. It seems to be old and needed for updates. 1-Author Response Thank you for pointing this out. We have updated the search to include studies published up to January 1, 2025. After rerunning the search using the same strategy, no additional articles matching the inclusion criteria were identified. Therefore, the original findings remain unchanged.​​​​​​​ 2- Reviewer Comment 2) “From 74 identified studies, outcome measures were categorized into groups like “Balance Improvement,” “Gait Improvement,” “Mobility Enhancement,” “Muscle Strength Improvement,” “Cognitive Function and Quality of Life,” and others” No need for all alternative words for measuring balance. The main measured outcome was balance. 2 -Author response Thank you for your feedback. We have revised the text to emphasize balance as the primary outcome measure while retaining the mention of secondary outcomes. The updated text now reads: "From 74 identified studies, the primary outcome measure was ‘Balance Improvement,’ while secondary outcomes included ‘Cognitive Function and Quality of Life,’ among others." This revision ensures clarity and aligns with the focus of the systematic review 3-Reviewer comment The excluded Articles criteria are not placed in the abstract. It is better to be placed in the methodology section. 3-Author response Thank you for the suggestion. We have removed the excluded articles criteria from the abstract and incorporated them into the Methodology section. 4-Reviewer comment The results for fall risks reduction were not mentioned in the result section in the abstract. It is your second measured outcomes as mentioned in the title and research aim. 4-Author response Thank you for your valuable feedback. We have revised the abstract's results section to explicitly mention fall risk reduction. The updated text now reads: "Treadmill training demonstrated positive effects on balance and fall risk reduction, particularly in elderly individuals with Parkinson’s disease, spinal cord injuries, and age-related balance issues. Perturbation-based treadmill training significantly reduced fall rates, while underwater treadmill sessions improved mobility and cognitive function." Introduction: 1-Reviewer comment You used present or future tense in writing “The review will rigorously”. Please use the past tense. “ The focus of this systematic review is to delve deep”. Do not use we or our, use the third pronoun like it was 1-Author response Thank you for your insightful feedback. We have revised the text to maintain consistency in past tense and third-person narration. The updated sentences now read: "The review rigorously evaluated..." (instead of “The review will rigorously...”) "The focus of this systematic review was to examine..." (instead of “The focus of this systematic review is to delve deep...”) Methodology: 1-Reviewer comment Use the updated for of PRISMA flow chart (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources). The new one included the Identification of studies via databases and registers and Identification of studies via other methods. 1-Author response Thank you for your valuable suggestion. We have updated the PRISMA flowchart to the PRISMA 2020 format , which now includes a more detailed representation of the study selection process. The revised flowchart distinguishes between identification of studies via databases and registers and identification via other methods as per the updated PRISMA guidelines. 2-Reviewer comment Mention the methods of identifying and removing the duplicates in different databases, the data extraction criteria, the used methods of methodological quality assessment. 2-Author response Thank you for your valuable feedback. We have now explicitly detailed the methods used for duplicate removal, data extraction, and quality assessment in the Methodology section . The revised text is as follows: Data were extracted independently by two reviewers using a structured data extraction form. Extracted variables included study design, sample size, participant characteristics, treadmill training protocol (duration, intensity, frequency), primary and secondary outcome measures, and key findings. Discrepancies between reviewers were resolved through discussion. After importing search results from multiple databases, duplicates were identified and removed by adding all the data in Microsoft excel, highlighting the duplicates and by manual screening. Risk of bias for each included study was evaluated using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. The Cochrane RoB 2.0 tool assessed five domains, including bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain was rated as low risk, some concerns, or high risk, with an overall rating assigned to each study. To enhance clarity, a traffic plot and a summary plot were generated to visually present the findings 3-Reviewer comment Why you split the table including subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals”. 3-Author response Thank you for your feedback. The table was originally split to enhance clarity and organization by grouping studies based on their primary focus areas. The subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals” was maintained to ensure a clear distinction between studies targeting neurophysiological improvements and those addressing general balance and mobility. However, based on your suggestion, we have revised the table format to ensure better coherence: Merged the table sections where appropriate to present a more unified dataset. Maintained logical categorization within a single table to improve readability without unnecessary fragmentation. Used clear subheadings instead of splitting tables to differentiate study categories while maintaining flow. 4-Reviewer comment Where the results of assessment of methodological quality in the result section. 4-Author response Thank you for your valuable feedback. We acknowledge that the assessment of methodological quality was not explicitly reported in the results section. To address this, we have now included a detailed summary of the methodological quality of the included studies. 5-Reviewer comment Discussion needs more extensive report of finding of this systematic review. 5-Author response Thank you for your valuable suggestion. We have expanded the Discussion section to provide a more comprehensive analysis of the key findings of this systematic review. The revised section now includes a more detailed synthesis of the results, highlighting the impact of treadmill training on balance improvement and fall risk reduction, along with its effects on secondary outcomes such as cognitive function and quality of life. The updated Discussion now explicitly contrasts the findings of included studies, addressing variations in study design, population characteristics, and intervention protocols. We have also included a comparative discussion of different treadmill training modalities, such as perturbation-based treadmill training and underwater treadmill training, emphasizing their relative effectiveness. Additionally, we have elaborated on the implications of these findings for clinical practice and rehabilitation, while also acknowledging existing research gaps and the need for future studies to establish standardized training protocols. ​​​​​​​Very thanks for your comments Thanks prof ,Mohamed Salah for your valuable & worthful comments and your suggestions The responses of author to all comments one by one 1-Comment1- Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. 1- Author response Thank you for your valuable suggestion. We have modified the title to align with your recommendation. The revised title is: "Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." Abstract 1 - Reviewer Comment Abstract: 1) Search until May 31, 2023. It seems to be old and needed for updates. 1-Author Response Thank you for pointing this out. We have updated the search to include studies published up to January 1, 2025. After rerunning the search using the same strategy, no additional articles matching the inclusion criteria were identified. Therefore, the original findings remain unchanged.​​​​​​​ 2- Reviewer Comment 2) “From 74 identified studies, outcome measures were categorized into groups like “Balance Improvement,” “Gait Improvement,” “Mobility Enhancement,” “Muscle Strength Improvement,” “Cognitive Function and Quality of Life,” and others” No need for all alternative words for measuring balance. The main measured outcome was balance. 2 -Author response Thank you for your feedback. We have revised the text to emphasize balance as the primary outcome measure while retaining the mention of secondary outcomes. The updated text now reads: "From 74 identified studies, the primary outcome measure was ‘Balance Improvement,’ while secondary outcomes included ‘Cognitive Function and Quality of Life,’ among others." This revision ensures clarity and aligns with the focus of the systematic review 3-Reviewer comment The excluded Articles criteria are not placed in the abstract. It is better to be placed in the methodology section. 3-Author response Thank you for the suggestion. We have removed the excluded articles criteria from the abstract and incorporated them into the Methodology section. 4-Reviewer comment The results for fall risks reduction were not mentioned in the result section in the abstract. It is your second measured outcomes as mentioned in the title and research aim. 4-Author response Thank you for your valuable feedback. We have revised the abstract's results section to explicitly mention fall risk reduction. The updated text now reads: "Treadmill training demonstrated positive effects on balance and fall risk reduction, particularly in elderly individuals with Parkinson’s disease, spinal cord injuries, and age-related balance issues. Perturbation-based treadmill training significantly reduced fall rates, while underwater treadmill sessions improved mobility and cognitive function." Introduction: 1-Reviewer comment You used present or future tense in writing “The review will rigorously”. Please use the past tense. “ The focus of this systematic review is to delve deep”. Do not use we or our, use the third pronoun like it was 1-Author response Thank you for your insightful feedback. We have revised the text to maintain consistency in past tense and third-person narration. The updated sentences now read: "The review rigorously evaluated..." (instead of “The review will rigorously...”) "The focus of this systematic review was to examine..." (instead of “The focus of this systematic review is to delve deep...”) Methodology: 1-Reviewer comment Use the updated for of PRISMA flow chart (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources). The new one included the Identification of studies via databases and registers and Identification of studies via other methods. 1-Author response Thank you for your valuable suggestion. We have updated the PRISMA flowchart to the PRISMA 2020 format , which now includes a more detailed representation of the study selection process. The revised flowchart distinguishes between identification of studies via databases and registers and identification via other methods as per the updated PRISMA guidelines. 2-Reviewer comment Mention the methods of identifying and removing the duplicates in different databases, the data extraction criteria, the used methods of methodological quality assessment. 2-Author response Thank you for your valuable feedback. We have now explicitly detailed the methods used for duplicate removal, data extraction, and quality assessment in the Methodology section . The revised text is as follows: Data were extracted independently by two reviewers using a structured data extraction form. Extracted variables included study design, sample size, participant characteristics, treadmill training protocol (duration, intensity, frequency), primary and secondary outcome measures, and key findings. Discrepancies between reviewers were resolved through discussion. After importing search results from multiple databases, duplicates were identified and removed by adding all the data in Microsoft excel, highlighting the duplicates and by manual screening. Risk of bias for each included study was evaluated using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. The Cochrane RoB 2.0 tool assessed five domains, including bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain was rated as low risk, some concerns, or high risk, with an overall rating assigned to each study. To enhance clarity, a traffic plot and a summary plot were generated to visually present the findings 3-Reviewer comment Why you split the table including subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals”. 3-Author response Thank you for your feedback. The table was originally split to enhance clarity and organization by grouping studies based on their primary focus areas. The subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals” was maintained to ensure a clear distinction between studies targeting neurophysiological improvements and those addressing general balance and mobility. However, based on your suggestion, we have revised the table format to ensure better coherence: Merged the table sections where appropriate to present a more unified dataset. Maintained logical categorization within a single table to improve readability without unnecessary fragmentation. Used clear subheadings instead of splitting tables to differentiate study categories while maintaining flow. 4-Reviewer comment Where the results of assessment of methodological quality in the result section. 4-Author response Thank you for your valuable feedback. We acknowledge that the assessment of methodological quality was not explicitly reported in the results section. To address this, we have now included a detailed summary of the methodological quality of the included studies. 5-Reviewer comment Discussion needs more extensive report of finding of this systematic review. 5-Author response Thank you for your valuable suggestion. We have expanded the Discussion section to provide a more comprehensive analysis of the key findings of this systematic review. The revised section now includes a more detailed synthesis of the results, highlighting the impact of treadmill training on balance improvement and fall risk reduction, along with its effects on secondary outcomes such as cognitive function and quality of life. The updated Discussion now explicitly contrasts the findings of included studies, addressing variations in study design, population characteristics, and intervention protocols. We have also included a comparative discussion of different treadmill training modalities, such as perturbation-based treadmill training and underwater treadmill training, emphasizing their relative effectiveness. Additionally, we have elaborated on the implications of these findings for clinical practice and rehabilitation, while also acknowledging existing research gaps and the need for future studies to establish standardized training protocols. ​​​​​​​Very thanks for your comments Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 23 Apr 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 10 Feb 25 read read Version 1 23 Apr 24 read read Mohamed Salaheldien Alayat , Cairo University, Faculty of Physical Therapy, Giza, Egypt; Umm Al-Qura University, Mecca, Saudi Arabia Adel Alhusaini , King Saud University, Riyadh, Saudi Arabia Hafsah Arshad , Ibadat International University, Islamabad, Pakistan Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Arshad H. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 12 Aug 2025 | for Version 2 Hafsah Arshad , Ibadat International University, Islamabad, Pakistan 0 Views copyright © 2025 Arshad H. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This systematic review is well-executed and scientifically sound. It meets all key criteria for transparency, methodological rigor, and clinical relevance. With minor enhancements for reproducibility, this article would represent a high-quality contribution to the field. The findings offer meaningful insights for clinical practice, policy formulation, and future research, particularly in guiding evidence-based interventions and improving patient outcomes. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Yes Competing Interests No competing interests were disclosed. Reviewer Expertise neurological physical therapy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Arshad H. Peer Review Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.177083.r394714) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-330/v2#referee-response-394714 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Alayat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Mar 2025 | for Version 2 Mohamed Salaheldien Alayat , Basic Science, Cairo University, Faculty of Physical Therapy, Giza, Egypt, Egypt; Physiotherapy and rehabilitation department, Faculty of Applied Medical science, Umm Al-Qura University, Mecca, Saudi Arabia 0 Views copyright © 2025 Alayat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors respond to all the reviewer comments in the revised version. Risk of bias was successfully added. I think paper now is ready for indexing. Competing Interests No competing interests were disclosed. Reviewer Expertise Physical Therapy, Rehabilitation, Therapeutic Modalities. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 19 Mar 2025 Moattar Rizvi, Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India Accepted View more View less Competing Interests Not Any reply Respond Report a concern Alayat MS. Peer Review Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.177083.r365510) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-330/v2#referee-response-365510 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Alhusaini A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Jan 2025 | for Version 1 Adel Alhusaini , Department of Health Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Riyadh Province, Saudi Arabia 0 Views copyright © 2025 Alhusaini A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This systematic review offers a significant contribution to understanding the efficacy of treadmill training in enhancing balance and reducing fall risk among older adults. The methodology encompasses a comprehensive literature search and analysis of approximately fifteen studies evaluating various treadmill training protocols. The findings suggest potential benefits for improving balance and mobility, particularly for individuals with Parkinson's disease or spinal cord injuries. The conclusions appear largely substantiated by the presented evidence, and the acknowledgment of limitations is appropriate. The authors rightly emphasize the significance of synthesizing disparate research. A recommendation for further investigation to optimize training protocols and address individualized needs is critical. However, several aspects warrant further consideration to enhance the review's clarity, rigor, and practical applicability. Methodological Clarity and Transparency: An inconsistency in the reported number of included studies (n=16 in the abstract versus n=15 in Table 1) warrants attention regarding transparency. The authors should explicitly state the final number of studies included within the results section and reconcile this discrepancy through verification and subsequent updates to both sections. Data Interpretation and Contextualization: Regarding Table 1: study by Hesse et al., 1997, updating the 'Study Type' field to 'Quasi-experimental study' is recommended if methodologically accurate. Furthermore, contextualizing the findings in relation to existing systematic reviews and meta-analyses would significantly enrich the review by providing a broader scholarly perspective and identifying areas of convergence or divergence. Methodological Rigor and Bias Assessment: Explicit reporting of blinding procedures within the included studies is necessary to facilitate a robust assessment of potential bias. Acknowledging limitations arising from the absence or non-reporting of blinding procedures is also crucial for a comprehensive evaluation of study quality. Please carefully review Table 1's columns and consider these revisions for clarity and conciseness: Change "Paper Title" to "Author(s), Year" without the title for easier reference and table management. Change "Study Type" to the more precise "Study Design." Revise "Population Characteristics" to "Participant Characteristics" and add an "Age" field for comprehensive participant details. Add a "Country/Setting" column to provide important contextual information, if possible. Combine "Intervention" and "Duration" into a single column for better readability (e.g., "Treadmill training, 8 weeks"). Add separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" of the studies. Include a column specifying the "Outcome Measurement Tools" used for each outcome. Furthermore, concerning citation analysis within Table 1, if a literature review is cited, it is essential to examine the original primary studies referenced within that review and include those primary studies in the systematic review if they meet the pre-defined inclusion criteria. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Developmental Disabilities, Early Mobility, Infant Movement, Motor Skills, Motor Control, Gait, Balance, Coordination, Assistive Technology, Childhood Obesity, Physical Function, Physical Activity, Sedentary Behavior, Participation Restrictions, ICF (Children), Outcome Measures & Assessment, Handwriting, Quality of Life (Pediatrics), Pediatric Rehabilitation, Early Intervention, Child Development, Motor Delay, Postural Control, Motivation, Self-Efficacy, Anxiety (Movement-Related), Social Participation, Family Involvement, Caregiver Burden, School Integration. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 16 Jan 2025 Moattar Rizvi, Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India Many Thank for prof. Adel Alhusaini for your valuable and worthful comments The responses for all reviewing comments one by one 1-Reviewer comment Methodological Clarity and Transparency: An inconsistency in the reported number of included studies (n=16 in the abstract versus n=15 in Table 1) warrants attention regarding transparency. The authors should explicitly state the final number of studies included within the results section and reconcile this discrepancy through verification and subsequent updates to both sections. 1-Author response Thank you for pointing out this inconsistency. Upon verification, the correct number of included studies is 15 , and the mention of 16 studies in the abstract was a typographical error . We have now updated the abstract, results section, and any other relevant parts of the manuscript to reflect the correct count ( n=15 ) to maintain accuracy and transparency. 2-Reviewer comment Data Interpretation and Contextualization: Regarding Table 1: study by Hesse et al., 1997, updating the 'Study Type' field to 'Quasi-experimental study' is recommended if methodologically accurate. Furthermore, contextualizing the findings in relation to existing systematic reviews and meta-analyses would significantly enrich the review by providing a broader scholarly perspective and identifying areas of convergence or divergence. Methodological Rigor and Bias Assessment: Explicit reporting of blinding procedures within the included studies is necessary to facilitate a robust assessment of potential bias. Acknowledging limitations arising from the absence or non-reporting of blinding procedures is also crucial for a comprehensive evaluation of study quality. 2- Author comments Thank you for your suggestion. The assessment of blinding procedures has been conducted using the Risk of Bias Tool (RoB 2 for RCTs) . The updated Results section now explicitly reports blinding practices within the included studies, identifying whether single, double, or no blinding was used. Additionally, we have now included a detailed bias assessment table to highlight the impact of blinding (or lack thereof) on study outcomes. In cases where blinding was not reported, the potential risk of performance and detection bias has been acknowledged. 3- Reviewer comment Please carefully review Table 1's columns and consider these revisions for clarity and conciseness: Change "Paper Title" to "Author(s), Year" without the title for easier reference and table management. Change "Study Type" to the more precise "Study Design." Revise "Population Characteristics" to "Participant Characteristics" and add an "Age" field for comprehensive participant details. Add a "Country/Setting" column to provide important contextual information, if possible. Combine "Intervention" and "Duration" into a single column for better readability (e.g., "Treadmill training, 8 weeks"). Add separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" of the studies. Include a column specifying the "Outcome Measurement Tools" used for each outcome 3- Author response Thank you for your detailed and valuable suggestions. We have carefully revised Table 1 to improve clarity, conciseness, and readability in accordance with your recommendations: The "Paper Title" column has been changed to "Author(s), Year" , listing only the author(s) and publication year for streamlined reference. "Study Type" has been updated to "Study Design" to ensure precision in methodological classification. "Population Characteristics" has been revised to "Participant Characteristics," and an "Age" field has been added to provide a clearer demographic profile of study participants. A new "Country/Setting" column has been included where possible to offer contextual insights into the study environments. The "Intervention" and "Duration" columns have been combined into a single column to improve table readability (e.g., "Treadmill training, 8 weeks"). Separate columns for "Primary Outcome(s)" and "Secondary Outcome(s)" have been added to distinguish key findings in a structured manner. . 4-Reviewer comment Furthermore, concerning citation analysis within Table 1, if a literature review is cited, it is essential to examine the original primary studies referenced within that review and include those primary studies in the systematic review if they meet the pre-defined inclusion criteria. 4- Author response Thank you for your insightful suggestion. We conducted a thorough citation analysis of the literature reviews included in Table 1 to identify relevant primary studies that could potentially meet our pre-defined inclusion criteria. However, upon careful examination, none of the primary studies referenced within the cited literature reviews met the eligibility criteria for inclusion in this systematic review. Many thanks for your efforts and worthful comments View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Alhusaini A. Peer Review Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.160679.r353972) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-330/v1#referee-response-353972 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Alayat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 31 Dec 2024 | for Version 1 Mohamed Salaheldien Alayat , Basic Science, Cairo University, Faculty of Physical Therapy, Giza, Egypt, Egypt; Physiotherapy and rehabilitation department, Faculty of Applied Medical science, Umm Al-Qura University, Mecca, Saudi Arabia 0 Views copyright © 2025 Alayat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. Abstract: 1) Search until May 31, 2023. It seems to be old and needed for update. 2) “From 74 identified studies, outcome measures were categorized into groups like “Balance Improvement,” “Gait Improvement,” “Mobility Enhancement,” “Muscle Strength Improvement,” “Cognitive Function and Quality of Life,” and others” No need for all alternative words for measuring balance. The main measured outcome was balance. 3) The excluded Articles criteria are not placed in the abstract. It is better to be placed in the methodology section. 4) The results for fall risks reduction were not mentioned in the result section in the abstract. It is your second measured outcomes as mentioned in the title and research aim. Introduction: You used present or future tense in writing “The review will rigorously”. Please use the past tense. “ The focus of this systematic review is to delve deep”. Do not use we or our, use the third pronoun like it was ….. Methodology: 1) Use the updated for of PRISMA flow chart (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources). The new one included the Identification of studies via databases and registers and Identification of studies via other methods. 2) Mention the methods of identifying and removing the duplicates in different databases, the data extraction criteria, the used methods of methodological quality assessment. 3) Why you split the table including subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals”. 4) Where the results of assessment of methodological quality in the result section. 5) Discussion needs more extensive report of finding of this systematic review. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Partly Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Physical Therapy, Rehabilitation, Therapeutic Modalities. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 16 Jan 2025 Moattar Rizvi, Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, 121004, India Thanks prof ,Mohamed Salah for your valuable & worthful comments and your suggestions The responses of author to all comments one by one 1-Comment1- Title: The title containing “geriatric care” and “elderly population”. Use one of them only. Suggested title” efficacy of treadmill training on balance and fall risks in elderly population. A systematic review”. 1- Author response Thank you for your valuable suggestion. We have modified the title to align with your recommendation. The revised title is: "Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." Abstract 1 - Reviewer Comment Abstract: 1) Search until May 31, 2023. It seems to be old and needed for updates. 1-Author Response Thank you for pointing this out. We have updated the search to include studies published up to January 1, 2025. After rerunning the search using the same strategy, no additional articles matching the inclusion criteria were identified. Therefore, the original findings remain unchanged.​​​​​​​ 2- Reviewer Comment 2) “From 74 identified studies, outcome measures were categorized into groups like “Balance Improvement,” “Gait Improvement,” “Mobility Enhancement,” “Muscle Strength Improvement,” “Cognitive Function and Quality of Life,” and others” No need for all alternative words for measuring balance. The main measured outcome was balance. 2 -Author response Thank you for your feedback. We have revised the text to emphasize balance as the primary outcome measure while retaining the mention of secondary outcomes. The updated text now reads: "From 74 identified studies, the primary outcome measure was ‘Balance Improvement,’ while secondary outcomes included ‘Cognitive Function and Quality of Life,’ among others." This revision ensures clarity and aligns with the focus of the systematic review 3-Reviewer comment The excluded Articles criteria are not placed in the abstract. It is better to be placed in the methodology section. 3-Author response Thank you for the suggestion. We have removed the excluded articles criteria from the abstract and incorporated them into the Methodology section. 4-Reviewer comment The results for fall risks reduction were not mentioned in the result section in the abstract. It is your second measured outcomes as mentioned in the title and research aim. 4-Author response Thank you for your valuable feedback. We have revised the abstract's results section to explicitly mention fall risk reduction. The updated text now reads: "Treadmill training demonstrated positive effects on balance and fall risk reduction, particularly in elderly individuals with Parkinson’s disease, spinal cord injuries, and age-related balance issues. Perturbation-based treadmill training significantly reduced fall rates, while underwater treadmill sessions improved mobility and cognitive function." Introduction: 1-Reviewer comment You used present or future tense in writing “The review will rigorously”. Please use the past tense. “ The focus of this systematic review is to delve deep”. Do not use we or our, use the third pronoun like it was 1-Author response Thank you for your insightful feedback. We have revised the text to maintain consistency in past tense and third-person narration. The updated sentences now read: "The review rigorously evaluated..." (instead of “The review will rigorously...”) "The focus of this systematic review was to examine..." (instead of “The focus of this systematic review is to delve deep...”) Methodology: 1-Reviewer comment Use the updated for of PRISMA flow chart (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources). The new one included the Identification of studies via databases and registers and Identification of studies via other methods. 1-Author response Thank you for your valuable suggestion. We have updated the PRISMA flowchart to the PRISMA 2020 format , which now includes a more detailed representation of the study selection process. The revised flowchart distinguishes between identification of studies via databases and registers and identification via other methods as per the updated PRISMA guidelines. 2-Reviewer comment Mention the methods of identifying and removing the duplicates in different databases, the data extraction criteria, the used methods of methodological quality assessment. 2-Author response Thank you for your valuable feedback. We have now explicitly detailed the methods used for duplicate removal, data extraction, and quality assessment in the Methodology section . The revised text is as follows: Data were extracted independently by two reviewers using a structured data extraction form. Extracted variables included study design, sample size, participant characteristics, treadmill training protocol (duration, intensity, frequency), primary and secondary outcome measures, and key findings. Discrepancies between reviewers were resolved through discussion. After importing search results from multiple databases, duplicates were identified and removed by adding all the data in Microsoft excel, highlighting the duplicates and by manual screening. Risk of bias for each included study was evaluated using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. The Cochrane RoB 2.0 tool assessed five domains, including bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain was rated as low risk, some concerns, or high risk, with an overall rating assigned to each study. To enhance clarity, a traffic plot and a summary plot were generated to visually present the findings 3-Reviewer comment Why you split the table including subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals”. 3-Author response Thank you for your feedback. The table was originally split to enhance clarity and organization by grouping studies based on their primary focus areas. The subtitle “Treadmill Training for Neurophysiological Improvement in Diseased and Elderly Individuals” was maintained to ensure a clear distinction between studies targeting neurophysiological improvements and those addressing general balance and mobility. However, based on your suggestion, we have revised the table format to ensure better coherence: Merged the table sections where appropriate to present a more unified dataset. Maintained logical categorization within a single table to improve readability without unnecessary fragmentation. Used clear subheadings instead of splitting tables to differentiate study categories while maintaining flow. 4-Reviewer comment Where the results of assessment of methodological quality in the result section. 4-Author response Thank you for your valuable feedback. We acknowledge that the assessment of methodological quality was not explicitly reported in the results section. To address this, we have now included a detailed summary of the methodological quality of the included studies. 5-Reviewer comment Discussion needs more extensive report of finding of this systematic review. 5-Author response Thank you for your valuable suggestion. We have expanded the Discussion section to provide a more comprehensive analysis of the key findings of this systematic review. The revised section now includes a more detailed synthesis of the results, highlighting the impact of treadmill training on balance improvement and fall risk reduction, along with its effects on secondary outcomes such as cognitive function and quality of life. The updated Discussion now explicitly contrasts the findings of included studies, addressing variations in study design, population characteristics, and intervention protocols. We have also included a comparative discussion of different treadmill training modalities, such as perturbation-based treadmill training and underwater treadmill training, emphasizing their relative effectiveness. Additionally, we have elaborated on the implications of these findings for clinical practice and rehabilitation, while also acknowledging existing research gaps and the need for future studies to establish standardized training protocols. ​​​​​​​Very thanks for your comments View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Alayat MS. Peer Review Report For: Efficacy of Treadmill Training on Balance and Fall Risks in the Elderly: A Systematic Review." [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :330 ( https://doi.org/10.5256/f1000research.160679.r351604) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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