Title: Effect of pelvic floor muscle training using mobile health applications for stress urinary
incontinence in women: a systematic review.
Version: 3 Date: 03 Aug 2022
Reviewer's report:
Thank you for a  comprehensive and timely response to my comments, and for the revised
manuscript.
I have the following comments:
1. the inconsistencies between the protocol and the submitted manuscript. Thank you for your
explanations. However, it is not enough to explain to me what you have done. This must be
included in the paper. Your methods section should note the changes you made in methods.
Explain why you changed the primary outcome (after you began the review).  Also, you need to
explain in the methods that a meta-analysis was planned and you decided not to do this giving
the reasons why.  Of course it is fine to decide not to pool the data but as you planned to do  it
you need to explain why you did not. Finally, in the results you need to explain that you found
only (a) studies in English and (b) studies in women with SUI. These are both RESULTS of
your methods . These are actually interesting results! Please make sure your background (and
abstract) state the ORGINAL review question (e.g. to conduct a systematic review with meta-
analysis to investigate the effects of app-based PFMT versus usual treatment on adherence and
symptom severity in women with SUI and MUI). It is not appropriate to change the research
question - what you changed (which was appropriate given what you found) was the methods.
2. Section 2.2. This still does not define PFMT or smartphone apps (i.e. the type of intervention
eligible for inclusion). In addition, it is important to make it clear what control interventions are
eligible, e.g. did the trial have to compare PFMT + app versus PFMT without an app or did you
also include PFMT + app versus no treatment? Of course, what the control arm does can have a
big influence on the observed size and direction of effect so it's important to make this very clear.
3.  Section 2.6. I presume that you mean you used the Risk of Bias -1 rather than Risk of Bias-2
tool. Having assessed risk of bias as is expected in a systematic review, it is also expected that
you include this in your synthesis of the data, whether than is a meta-analysis or a narrative
synthesis. On of the biggest criticisms of systematic reviews is that risk of bias is assessed and
then no use is made of that assessment.  You do report the risk of bias assessment in section 3.3
but then you don't use it at all in summarising the data. Which of these data, if any, do you trust
more? What difference does that make in your summary of the evidence. How much certainty
or uncertainty do you feel in statements like "a significant decrease in ICIQ-UI SF scores was
seen" or that there was "an increase in the self-efficacy scores". That might be the case but do
you have any cautions or concerns about the studies that have those findings given that you felt
only two of your studies had low risk of bias.
4. Change "measurement time" to  "timing of outcome measurement"
5.  Measurement of adherence. It sounds like you are reporting the result as methods. What
measures of adherence did you pre-specify? If you did not prespecify any, but would accept any
measure of adherence reported by the trialists then please say that. Then, in the results you can
make it clear that only Broome and self-report were used.
6. Unfortunately there is still a misunderstanding in this paper about the number of studies. There
are NINE included PUBLICATIONS. But these report ONLY SIX TRIALS. Please make this
absolutely clear. Unfortunately if you say there are nine studies it sounds like there is much more
research than there really is. Please also correct this in the tables. Each TRIAL should appear only
once. It is more confusing to the reader to see a single trial presented multiple times (especially
when the name of the first author can change in the follow up studies). Because you know these
studies and data so well you are not confused by it, but readers can easily misunderstand.
7.  Regarding my original comments about the overall results, I am sorry if I did not make myself
clear. It seems you have made no changes to how the results are reported and this is unfortunate
because so much is summarised in the text it is harder for the reader to see the most important
data. In a RCT the most important finding is the BETWEEN GROUP DIFFERENCE (e.g. there
was a mean difference of x (SD) in the ICIQ-UI SF between the app and non-app groups at the
end of treatment). Please do NOT report within group difference in the text (e.g. the app training
group improved from x to y, and the non-app group improved from  w to z). These data are a
distraction.  The within group difference can be in the tables for the interest of the readers but
this is not the effect of interest in an RCT.