PONE-D-20-06716

Reliability of Thumb Localizing Test and its validity against quantitative measures with a robotic device in patients with hemiparetic stroke

PLOS ONE

Dear Dr. Otaka,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

As you will see below, the two Reviewers point to some issues regarding the methodological approach and the interpretation of the results.  Reviewer#1 asks for clarifications about the methods and more detailed descriptions of the tests used (e.g. Fugl-Meyer). The Reviewer also has several suggestions to improve the Introduction and Discussion. Reviewer#2 has some concerns regarding the TLT scoring scheme and how this might have affected the reliability. Please make sure that all concerns are adequately addressed in the revised version.

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François Tremblay, PhD

Academic Editor

PLOS ONE

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2. Thank you for stating the following in the Competing Interests section:

"M.L., M.K. and J.U. are the founding scientists of Connect Inc., a commercial company for the development of rehabilitation devices since May 2018. They have received a salary from Connect Inc., and have held the shares in Connect Inc. They hold the managerial positions at Connect Inc. Their conditions were disclosed to the Universities, and were approved. Connect Inc. does not have any relationship with the present study. The other authors report no conflict of interest."

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3. We note that Figure 1 includes an image of a participant in the study.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear study authors

Thank you for the opportunity to review your manuscript. You have undertaken a study to determine the inter-rater validity of the thumb localising test in a chronic stroke population, and to examine its correlation with the KINARM exoskeleton device.

Firstly, thank you for the figures. They are very useful in these types of studies. Your study is nicely summarised and clear, however I feel you are currently missing a few important details that would assist readers. I have provided some comments below for your consideration. I hope these are helpful.

Major comments.

Introduction / References: Your background studies and references and all starting to get quite old. There is newer work in this area. Can you please incorporate discussion of more recent findings throughout the manuscript, and further discuss the implications for your methods and results. How does this work fit into other studies in both stroke and proprioception?

Methods: As you are undertaking an inter-rater validity study, please provide details on the raters, including their training, experience, and professional background). Was the person helping the participant a different person to the assessors, and if so please also add details on who they are.

Please explain the Fugl-Meyer and the Ashworth tests in more detail, including how you undertook them, the scoring (max score and how scored) and interpretation of the scores (i.e. a high Fugl-Meyer score is?). Also, please state which side you are reporting the Fugle-Meyer for (ie. More affected, less affected).

What are the time intervals between testing, were they all done on the same day, different days etc. how did you manage fatigue in these participants?

Results: Please put the results for each variable in a table in addition to the figures. Especially for the TLT results which do not appear to be reported at present.

Discussion: There are some terms in your discussion that have not been introduced earlier. Please give a short description of what you mean by these terms (i.e. kinaesthetic sensation, spatial cognition. How do you think the changes that may have occurred in the brain after the stroke has influenced your findings?

Limitations: You could expand on your limitations section, particularly;

You have briefly mentioned it, but you seen to have a fairly young and very high functioning cohort. This does not seem overly typical of a normal stroke population. Similarly, do you think your test would be as accurate in a less high functioning population? Please expand on this limitation.

Are you likely to see these changes with age, or are they purely due to the stroke?

You have mentioned in the introduction the TLT is only an ordinal test, however what does this for interpretation of your results.

Minor comments:

Table 1: You may wish to relabel “types of disease”, as Stroke type, or type of stroke.

Line 330 – typo – “grades” rather than grads.

309 – do you mean the study did “not” show significant correlations?

Reviewer #2: This is a well-written manuscript examining the inter-rater reliability of the Thumb Localizer Task in 40 participants with chronic stroke. Additionally, the authors make comparisons of the TLT results with those obtained from a well validated robotic measure of proprioception called position matching performed in the KINARM robot. The methodologic approach appears quite reasonable. My main suggestions with the paper are fairly minor.

The authors might consider making the point that the TLT is only a 4 point scale, and although it would theoretically be possible to get low reliability when doing such an experiment, not obtaining high inter-rater reliability from two trained observers scoring the same video of a patient would present quite a challenge.

The authors should also take a little more time to explain why they used the “vision restored” conditions.

“though it is a four-point scale and thus unable to quantify the deficits.” Although I agree with the authors a 4 point ordinal scale isn’t exactly the most desirable tool to “quantify” something. However the definition of the word “quantify” basically means you are trying to measure something and the TLT does this. I would suggest rewording the sentence accordingly.

Figures 1, 2 – The image on the PDF file I received was quite pixelated. The authors should consider addressing this prior to publication (I have seen this happen with some of my own manuscripts when the file gets converted by the publisher’s software, sometimes changing the file type can be helpful).

Discussion

Figures 4, 5 - It would have been nice here to also see Variability and Shift plotted in a similar way against TLT. Consider turning these into 3 panel figures to display all the data.

Page 14 – “significantly deteriorated” implies that the vision restored condition was conducted first, then the vision occluded. I suspect the authors meant “was significantly worse” or similar.

The authors may want to consider reviewing/discussing/contrasting a larger study investigating the return of vision (Herter et al. Vision does not always help stroke survivors compensate for impaired limb position sense. J Neuroeng Rehabil 2019.) as it uses the same task and many subjects fail to improve with vision restored.

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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PONE-D-20-06716R1

Reliability of the Thumb Localizing Test and its validity against quantitative measures with a robotic device in patients with hemiparetic stroke

PLOS ONE

Dear Dr. Otaka,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

As you will see below, the Reviewers were mostly satisfied with the latest version. Reviewer #2 has some minor points that will require your attention. I urge you to proceed with these corrections with diligence, as there will be no need for another round of review, provided that the minor points are adequately addressed.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

François Tremblay, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Thanks to the authors for responding to my previous review. The paper appears much improved. I did catch a few minor details that they authors should likely deal with.

Line 50 – actually the longitudinal process following stroke recovery has been discussed in a few papers, one that uses the same device the authors are using in the present manuscript (see Semrau et al. 2015, Stroke “Examining Differences in Patterns of Sensory and Motor Recovery After Stroke With Robotics”. There are also a few papers that use clinical scales to look at recovery of proprioception and a reasonably sized recent one published in Neurorehabilitation and Neural Repair (“Zandvliet et al. 2020 34(5):403-426 “Is Recovery of Somatosensory Impairment Condition for Upper-limb motor recovery after stroke?”). So the authors may want to soften the existing comment and reference studies that have looked at it. I completely agree there is room for further, more detailed studies here, but they authors should not ignore the efforts of others that have already looked at this issue.

Line 106 – Fugl-Meyer. The upper score should be 66 here (I think the 36 is a typo).

Line 314 – I suspect you mean “quantitative” rather than “qualitative” measure as it is written.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Reliability of the Thumb Localizing Test and its validity against quantitative measures with a robotic device in patients with hemiparetic stroke

PONE-D-20-06716R2

Dear Dr. Otaka,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

François Tremblay, PhD

Academic Editor

PLOS ONE

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Reviewers' comments: