PONE-D-24-37522Improvement in quality of life and cognitive function in Post Covid Syndrome after online occupational therapy: results from a randomized controlled pilot studyPLOS ONE

Dear Dr. Stölting,

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.

Please submit your revised manuscript by Mar 28 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Yalong Dang

Academic Editor

PLOS ONE

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2. Thank you for stating the following financial disclosure: 

The project received funding through the German Federal Ministry for Education and Research 

(Grant number 01EP2103C)

Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." 

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Additional Editor Comments :

Reviewer 1: Line 70: to state ‘explore efficacy ‘ as 'efficacy' is generally not the primary focus of feasibility study.

Line 72: the word ‘underpowered’ is to be removed since no sample size was calculated.

Line 75: typo ‘The aim of the here’.

Line 102, 105-107: a separate list of exclusion criteria is to be provided. The participants were required to fill in the assessment tools/inventories/questionnaires, and some of the tools may require some level of understanding, either in English or German. Is the level of education one of the criteria?

This language of communication/used in this study is to be clearly stated, e.g., for emails, questionnaires, interviews, participant information sheets, consent forms, etc.

Line 129-137,146-147: the language and mode of administration of the tools/questionnaires are to be stated.

Line 139-141: the sentence requires revision.

Line 150: the reason for using the Wilcoxon signed-ranked test is to be stated.

Line 151-153: the exact name of the statistical test is to be stated.

Line 154-155: the information on the missing values/data is to be provided, e.g., percentage missing data, the pattern of missing data, etc. Describe the application of LOCF considering the characteristics of the dropout participants, e.g., any changes in the outcome, etc. If there is a significant number of dropout participants during follow-up, it is recommended to use the multiple imputation method.

Line 155-156: sentence ‘As sensitivity analysis adjusted between-group differences were reported with missing data excluded’ requires revision.

Line 157: the level of the confidence interval is to be stated e.g. 95%.

Line 158: one or two-tailed test is to be stated.

Ensure all the statistical tests mentioned in the results section are stated in the methodology statistical analysis section.

Ensure the decimal points for the p values are consistent throughout the manuscript.

Line 186: typo p 0.04 (e.g. p=0.04)

Line 188: typo p 0.003 (e.g. p=0.003)

Line 190: typo p 0.01 (e.g. p=0.01)

Table 1, Table 2, Supplementary Table 1 & Table 3: the title is to be placed on top of the table.

Line 192-193 Table 1: male gender is to be presented apart from female. The table looks confusing. On the top, it was stated as total n, but there were figures missing in the variables column (left). For reader convenience, it is best to include the sample size (n) for each variable.

Apart from intent to treat analysis, per protocol analysis is to be presented.

Line 224-233 Table 2 & Supplementary Table 1: were the data normally distributed? The distribution assumption of the data should be specified. If the data is skewed, it requires transformation or applying an alternative statistical test.

Line 250-251 Table 3: the table is blurry. Avoid using screenshot table(s). If possible, all tables are to be drawn directly within the manuscript.

Line 254: Wilcoxon signed-rank test

Table 2, Supplementary Table 1 and Table 3: decimal points are to be standardized where applicable.

Effect size could be presented.

Some references did not conform to the journal format.

Reviewer 2: The manuscript titled "Feasibility and Efficacy of Online Occupational Therapy in Post-COVID Syndrome: A Pilot Randomized Controlled Trial" presents novel exploratory results regarding digital interventions for Post-COVID Syndrome (PCS).

Limitations: 1. significant baseline variability (age, sex, memory function) was not fully controlled or adjusted. 2. High dropout rates (e.g., 53.8% in the video group) challenge the internal validity and raise concerns about participant engagement. 3. Sample Size Limitation: No a priori power calculation was carried out, although the authors explianed this concern in Discussion. 4. Statistical analysis: methods such as "last observation carried forward" (LOCF) need justification given group differences and missing data.

Please revise the MS on the following aspects:1. Address baseline imbalances (e.g., adjust for age and sex). 2. Clarify objectives and align outcomes with hypotheses. 3. Strengthen statistical rigor with detailed subgroup analyses and fine-tune methodological transparency.

[Note: HTML markup is below. Please do not edit.]

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: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

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

**********

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

**********

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: Line 70: to state ‘explore efficacy ‘ as 'efficacy' is generally not the primary focus of feasibility study.

Line 72: the word ‘underpowered’ is to be removed since no sample size was calculated.

Line 75: typo ‘The aim of the here’.

Line 102, 105-107: a separate list of exclusion criteria is to be provided. The participants were required to fill in the assessment tools/inventories/questionnaires, and some of the tools may require some level of understanding, either in English or German. Is the level of education one of the criteria?

This language of communication/used in this study is to be clearly stated, e.g., for emails, questionnaires, interviews, participant information sheets, consent forms, etc.

Line 129-137,146-147: the language and mode of administration of the tools/questionnaires are to be stated.

Line 139-141: the sentence requires revision.

Line 150: the reason for using the Wilcoxon signed-ranked test is to be stated.

Line 151-153: the exact name of the statistical test is to be stated.

Line 154-155: the information on the missing values/data is to be provided, e.g., percentage missing data, the pattern of missing data, etc. Describe the application of LOCF considering the characteristics of the dropout participants, e.g., any changes in the outcome, etc. If there is a significant number of dropout participants during follow-up, it is recommended to use the multiple imputation method.

Line 155-156: sentence ‘As sensitivity analysis adjusted between-group differences were reported with missing data excluded’ requires revision.

Line 157: the level of the confidence interval is to be stated e.g. 95%.

Line 158: one or two-tailed test is to be stated.

Ensure all the statistical tests mentioned in the results section are stated in the methodology statistical analysis section.

Ensure the decimal points for the p values are consistent throughout the manuscript.

Line 186: typo p 0.04 (e.g. p=0.04)

Line 188: typo p 0.003 (e.g. p=0.003)

Line 190: typo p 0.01 (e.g. p=0.01)

Table 1, Table 2, Supplementary Table 1 & Table 3: the title is to be placed on top of the table.

Line 192-193 Table 1: male gender is to be presented apart from female. The table looks confusing. On the top, it was stated as total n, but there were figures missing in the variables column (left). For reader convenience, it is best to include the sample size (n) for each variable.

Apart from intent to treat analysis, per protocol analysis is to be presented.

Line 224-233 Table 2 & Supplementary Table 1: were the data normally distributed? The distribution assumption of the data should be specified. If the data is skewed, it requires transformation or applying an alternative statistical test.

Line 250-251 Table 3: the table is blurry. Avoid using screenshot table(s). If possible, all tables are to be drawn directly within the manuscript.

Line 254: Wilcoxon signed-rank test

Table 2, Supplementary Table 1 and Table 3: decimal points are to be standardized where applicable.

Effect size could be presented.

Some references did not conform to the journal format.

Reviewer #2: The manuscript titled "Feasibility and Efficacy of Online Occupational Therapy in Post-COVID Syndrome: A Pilot Randomized Controlled Trial" presents novel exploratory results regarding digital interventions for Post-COVID Syndrome (PCS).

Limitations: 1. significant baseline variability (age, sex, memory function) was not fully controlled or adjusted. 2. High dropout rates (e.g., 53.8% in the video group) challenge the internal validity and raise concerns about participant engagement. 3. Sample Size Limitation: No a priori power calculation was carried out, although the authors explianed this concern in Discussion. 4. Statistical Rigor: methods such as "last observation carried forward" (LOCF) need justification given group differences and missing data.

Please revise the MS on the following aspects:1. Address baseline imbalances (e.g., adjust for age and sex). 2. Clarify objectives and align outcomes with hypotheses. 3. Strengthen statistical rigor with detailed subgroup analyses and fine-tune methodological transparency.

**********

6. 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.

PONE-D-24-37522R1Improvement in quality of life and cognitive function in Post Covid Syndrome after online occupational therapy: results from a randomized controlled pilot studyPLOS ONE

Dear Dr. Stölting,

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.

Please submit your revised manuscript by May 21 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Yalong Dang

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

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: (No Response)

Reviewer #2: All comments have been addressed

**********

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: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: No

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: Yes

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: Yes

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: Minor comments:

Table 2 title: The abbreviation 'LOCF' is to be replaced.

Line 165: To state the assumptions for repeated measure ANOVA were fulfilled prior to use.

Reviewer #2: A nice job ready for publication after address the two minor points raised by Reviewer 1, thank you all authors.

**********

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.

Improvement in quality of life and cognitive function in Post Covid Syndrome after online occupational therapy: results from a randomized controlled pilot study

PONE-D-24-37522R2

Dear Dr. Stölting,

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.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Yalong Dang

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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

**********

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)

**********

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

Reviewer #1: (No Response)

**********

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)

**********

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)

**********

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)

**********

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

**********