Title: Effects of custom-made textile insoles on plantar pressure distribution and lower limb EMG activity during turning

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Raymond Preston
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1 Author s response to reviews Title: Effects of custom-made textile insoles on plantar pressure distribution and lower limb EMG activity during turning Authors: Kit-lun Yick (Kit-lun.yick@polyu.edu.hk) Del Wong (delwong.cuhk@gmail.com) Kit-lun Yick (Kit-lun.yick@polyu.edu.hk) Sun-pui Ng (ccspng@hkcc-polyu.edu.hk) Joanne Yip (joanne.yip@polyu.edu.hk) Version: 2 Date: 30 May 2016 Author s response to reviews: Ref. No.: JFAR-D Title: Effect of custom-made textile insoles on plantar pressure distribution and lower limb EMG activity during turning Reviewer #1: 1. Thank you for revising the paper titled: Effects of custom-made textile insoles on plantar pressure distribution and lower limb EMG activity during turning. The revised article is much improved and I do not have any new or additional queries. I do feel that the article would benefit from some language corrections. I will point out a few examples: a) Discussion page 10 line 43, fourth word extant?

2 Response: We apologize for any confusion. The word is now revised as below. While much of existence research has focused. b) line 58 missing full stop Response: Thank you for pointing this out. The full stop is added. c) Page 11 line the sentence starting 'Regarding of the insole...' needs to be rewritten. Response: Thank you for your comments. The sentence is revised as below: In regard to the insole composing of two-layer textile materials (i.e. Insole III), the pressure loading are significantly reduced in Toes and MTH 1during TE. d) Page 11 line 43 the sentence currently starting: Of which, needs to be rewritten., and Page 11 line 45 the sentence starting 'Insole II' needs to be rewritten. Response: As suggested, the sentence is revised as below. This may be attributed to the soft sandwiched structure of spacer fabrics that they are used as the top layer of Insoles II and III with direct contact with the foot for better resilience and recovery performance [32, 34], thus enhancing the overall foot-insole accommodation. In this case, Insole II tends to have a more pronounced pressure reduction effect. Insole II, which is made of spacer fabric X and Poron as the top accommodation layer and middle cushioning layer respectively, might effectively enhance pressure relief; whereas Insole III, which is made of spacer fabric Y with a lower resilience to compressibility because of its low pile height and

3 interlacing density structure, might show a comparatively lower pressure reduction performance than Insole II [31, 45]. e) Page 13 line 2 the sentence starting 'At present study' Response: Thank you for your comment. The sentence is revised as below. In the present study, the textile-fabricated insoles composing of the sandwich feature of spacer fabric could reduce the pressure loading at various regions ( % at MTHs 2-3 and % at heel area) during different phases of turning when compared to Insole I that made of EVA. The findings here could provide potential solutions to modify insole materials in future studies so as to optimize orthotic effects using biomechanical analyses. Reviewer #2: 1. Line 33. The subjects went through a 4-hour habituation period for each insole condition for 3 to 4 days before the data acquisition. Thank you for explaining the rationale behind the habituation period. This explanation should be incorporated within the text for the benefit of readers. The dosage and timing of the habituation seems a little random is there a reference to support the use of this protocol. The sentence describing the habituation period is still not clear and should be reworded; My current interpretation of a 4 hour habituation period for each of the 3 insoles is that total of habituation period included 12 hours of insole wear was undertaken! - can authors clarify within the text if this is correct. The extent and duration of the habituation period has not been Response: Thank you for your suggestion. The rationale behind the habituation period is added within the text as below. It is note that the habituation period is necessary for neurophysiological adaption, however, the extent and duration of this has not been documented [1]. The decision of 4 hour

4 habituation period is a commitment to participants on the basis of their daily activities and experience on footwear. For the description of the habituation period, subjects wore each insole condition for 4 hours before the wear trials. A total of 12-hour habituation period of insole wear was undertaken. This information is also revised as below for better understanding. Test protocol The data for each subject were collected on the same day. The subjects went through a 4-hour habituation period of each insole wear (i.e. 12 hours of insole wear in total for 3 insole conditions) for 3 to 4 days before the data acquisition. Previous studies have found that subjects, especially those with healthy foot conditions, probably feel uncomfortable for the contoured shape of the insoles and the overall comfort is likely influenced by arch comfort [37]. In this study, the tested insoles, are all custom-made with a contoured shape and arch support. The 4- hour habituation period is used for neural adaptation in the sensory nerves acclimating the contour shape in response to standing, walking and turning motion.." 2. Thank you for clarifying the use and type of standard footwear used during data collection. This information should be included within the text. Response: As suggested, the information is addressed in the text as below. Plantar pressure distribution measurement The participants wore the standard sports shoes, socks and insoles provided during data collection. 3. Results: The authors have improved the clarity of results by removing the misleading presentation of none significant results. However the presentation of the results from the ANOVA could be better; When presenting one-way repeated measures ANOVA effect size (eta) should be included.

5 Response: Thank you for your comment. The eta ( ) is added in the result Table When presenting significant pairwise comparisons: It would be more meaningful to the reader if the authors could add the mean difference and percent change in peak pressure reduction to the text preferably including sig diff and SD or 95% CI. Response: 3 As suggested, the mean difference, SD, percent change of reduction and significant different are addressed in the text of Result as below. Result Peak pressure.the Bonferroni pair-wise comparison results indicate that the PP of Insoles II is significantly lower than that of Insole I at toes (mean difference (SD): 34.4 (5.5), % change: 24.0%, p<0.001), MTH 1(22.7(8.4), 16.3%, p=0.01) and medial MF (9.6(1), 16.0%, p=0.012) during IN, and medial MF (11.6(3.0), 15.8%, p=0.041) and medial heel (23.7(6.8), 19.1%, p=0.005) during TR. Insole III displayed significantly lower PP than Insole I at hallux (27.5(0.7), 18.4%, p=0.011), toes (26.4(1.8), 18.0%, p=0.007) and MTH 1 (23.0(0.3), 18.7%, p=0.03) during TE. Pressure-time integral The PTI of Insole II at toes (9.4(2.0), 23.7%, p=0.001) and MTH 1 (7.8(1.0), 19.5%, p=0.007) of IN, as well as hallux (8.8(0.4), 19.2%, p=0.02), medial MF (5.3(0.9), 17.2%, p=0.025) and medial heel (11.0(5.3), 24.5%, p=0.007) of TR is significantly lower than Insole I in the pair-wise comparison. The PTI of Insole III is significantly smaller than that of Insole I at the toes (9.4(2.0), 18.5%, p=0.024) and MTH 1 (7.9(2.4), 23.9%, p=0.013) during TE.. Maximum muscle activity

6 The results in Table 4 indicate that a significant difference (p<0.05) is detected only in the VL muscle across insoles during TR, where the maximum value of Insole III is significantly lower (3.8(0.1), 16.9%, p=0.044) than that of Insole I in the pair-wise comparisons. 5. Discussion: The authors have still not discussed the findings of their study within the context of other work in the area. For example the authors should be able to summarise the reduction in peak pressure (in % terms) reported by other studies when investigating the effects of a similar standard EVA insoles. The findings of this study could then be placed within the context of other work, and any differences debated. Response: Thank you for pointing this out. The summary of other studies relating to EVA insoles together with peak pressure reduction value in % are addressed within the context as below. Discussion 7th paragraph Related studies have reported that plantar peak pressure is redistributed across the plantar with the insertion of contoured shape insoles when compared to no insole condition. In Redmound s study, custom made insoles with EVA insertion at heel posts could reduce peak pressure 12.7% and 17.2% at heel area when compared to prefabricated insole and control shoe conditions respectively [52]. Hinz indicated that wearing EVA insoles with anatomically shape could reduce the average pressure values at MTHs 2-3 by 9.7% to 11.4% as compared to the conventional insoles [53]. In the present study, the textile-fabricated insoles composing of the sandwich feature of spacer fabric could reduce the pressure loading at various regions ( % at MTHs 2-3 and % at heel area) during different phases of turning when compared to Insole I that made of EVA. The findings here could provide potential solutions to modify insole materials in future studies so as to optimize orthotic effects using biomechanical analyses. References [1] Redmond AC, Landorf KB, Keenan AM., "Contoured, prefabricated foot orthoses demonstrate comparable mechanical properties to contoured, customised foot orthoses: a plantar pressure study," Journal of foot and ankle research, vol. 2, p. 20, 2009.

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