PONE-D-24-30440The effect of a cognitive dual-task on the control of wheelchair propulsionPLOS ONE

Dear Dr. Salm,

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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: Partly

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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:  The clearly written manuscript is highly relevant and presents important findings for wheelchair users and research that has been conducted in this field today generally ignoring the effect of cognitive dual-task on propulsion technique. Suggested modifications:

- Missing link to why this information is valuable and what is the impact of reduced performance in propulsion control, specifically I am missing the link to shoulder loads, injury, and pain.

- Furthermore, while the authors spend an extensive amount of time to compare the literature to cognitive dual-task on walking (I believe more then 50% of the references refers to walking), it is not clear to me why this comparison is valuable and what it adds? You could rather try to include more references to the cognitive task of wheelchair propulsion itself: e.g. https://www.ideals.illinois.edu/items/125182, https://ieeexplore.ieee.org/abstract/document/9086088

- In the abstract it is no clear how you defined ‘practiced’ and ‘unpracticed’. In general, suggest referring to e.g. manual wheelchair users and novices, instead.

- Line 36-43: this section is a bit unclear to me and difficult to follow. PASAT needs to be defined.

- Line 62-64: either explain the tests here or don’t go in so much detail and rather explain that multiple tests are being used… .

- Line 129: which marker set did you use?

- Line 162: what is this spoke-marker exactly, is it an IMU? Describe and explain.

- Line 262: the novice wheelchair users were already propelling with the most simplified / likely least cognitive demanding way of propelling offering less freedom to change? Experienced wheelchair users may also be more flexible to adapt their propulsion style depending on the cognitive requirement. Generally, as your data nicely shows, experienced wheelchair users apply longer, smoother strokes, as the cognitive requirements increases it is very interesting to see that their style is changing. This is a critical finding and to me most important.

- Line 285-287: again why is the comparison to walking valuable? What does it add, would sign shorten here.

- Line 337-338: This is a nice recommendation, you could make it stronger that your results with this new ‘marker’ follow the findings of e.g. push angle differences etc.

Reviewer #2:  Titled “The effect of a cognitive dual-task on the control of wheelchair propulsion”, the present study investigates the effects of dual-task conditions on wheelchair propulsion by adapting the dual-task methodology to wheelchair users. To examine how an additional cognitive task (the Paced Auditory Serial Addition Test, PASAT) affects wheelchair propulsion, 52 participants were divided into two groups: practiced (n=38) and unpracticed (n=14) wheelchair users. The key finding of the study is that dual-task conditions influence spatiotemporal propulsion parameters, with most significant changes observed in the practiced group.

Whilst the study strengths include the innovative approach (applying the dual-task paradigm, usually limited to walking studies, to wheelchair propulsion), use of advanced technology, clear division of groups, and novel methodology to quantify the distance between the hand and the pushrim, relevant limitations must be recognized since they may limit the generalizability of the results. In fact, the study weaknesses are the relatively small sample size for the unpracticed group (n=14), limiting the statistical power to detect significant differences in some propulsion parameters, lack of real-world conditions, gender imbalance (particularly in the practiced group: 27 males, 11 females), and the limited cognitive task variability. While the PASAT test is well-suited for assessing divided attention and working memory, using additional cognitive tasks could provide more comprehensive insights into how different types of cognitive loads (e.g., visual vs. auditory distractions) affect propulsion behavior.

The manuscript addresses an important and valuable topic, still there are certain inconsistencies that need to be resolved. Additionally, the research area lacks a comprehensive analysis of the literature. To enhance the rigor and quality of the study, specific revisions are required.

Overall comments:

1. The introduction needs to be strengthened.

2. Important statistical information is needed.

3. The discussion section has to be improved.

Specific comments:

Title

The study design can be included in the title.

Abstract

Please provide some basic demographic information such as means and standard deviation for the age and percentage of female participants (XX±YY years; F=ZZ%).

Please indicate the p values for the main reported statistical significances.

Introduction

Although the introduction is clear, it could be improved as follows:

1. Introducing general statistics on wheelchair users and the barriers they face could significantly enhance the introduction by highlighting the broader societal relevance of the study. These statistics provide context, establish the scale of the problem, and emphasize the importance of improving mobility solutions for wheelchair users.

2. Incorporating relevant studies that contextualize the current research examining movement dynamics and dual-task performance in other populations which often suffer movement limitations like older adults. See for instance: Ciaccioni, S., Capranica, L., Forte, R., Pesce, C., & Condello, G. (2020). Effects of a 4-month judo program on gait performance in older adults. The Journal of Sports Medicine and Physical Fitness, 60(5), 685-692.

3. Clarifying the research gap more explicitly.

Methods

Participants

The ethics review board approval date missing.

Please clarifying the study design (e.g., cross-sectional study) typology.

Procedures

Figure 1: clear.

Considering the mental arithmetic calculative nature of the PASAT test, have the authors asked the participants whether they had any issues with number-processing and calculation such as dyscalculia? For more information, see: Hiscock, M., Caroselli, J. S., & Kimball, L. E. (1998). Paced serial addition: Modality-specific and arithmetic-specific factors. Journal of clinical and experimental neuropsychology, 20(4), 463-472.

Data processing and statistical analysis

Please indicate whether there were missing data and how they have been eventually treated.

The authors should present their reasons for recruiting and selecting the number of people included and analyzed, for instance noting the statistical power of the study. A paragraph may explain the sample size needed to detect a hypothesized difference in outcomes.

To provide meaningful analysis for comparisons from small groups, please provide a measure of effect sizes (e.g., Cohen’s d).

Results

They are clear.

Tables 1 and 2

Clear

Discussion

Although the discussions are solid and well-organized, they sometimes use a too colloquial language (e.g., “If you see the recovery phase when driving a wheelchair…”). Moreover, a review of the literature is needed to compare the results with specific studies on sport and dual-tasks.

Please highlight better the limitations of the present research.

Suggestions for improvement and future studies should encompass: 1. Recruiting a larger and more balanced sample, particularly for the unpracticed group. A more diverse participant pool would allow for more detailed subgroup analyses, such as comparing users with different levels of experience or physical ability; 2. Incorporate real-world conditions, measuring wheelchair propulsion on different surfaces (e.g., pavement, grass) or in the presence of visual and auditory distractions to provide a more comprehensive understanding of how dual-task conditions affect wheelchair use in everyday life; 3. Broadening the cognitive task selection that simulate everyday distractions, such as talking on the phone or navigating visually busy environments, could yield more ecologically valid results; and 4. Considering gender differences, particularly analyzing whether gender-specific factors, such as upper body strength, impact propulsion under cognitive load.

Conclusions

Overall positive. Please revise it after improving the discussion section.

References

Please double-check the correctness of all references, according to the journal guidelines.

Please consider expanding the references after a specific review of the sport and dual task-related literature.

Supplementary Materials:

Clear.

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Reviewer #1: Yes:  Fransiska M Bossuyt

Reviewer #2: Yes:  Simone Ciaccioni

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The effect of a cognitive dual-task on the control of wheelchair propulsion

PONE-D-24-30440R1

Dear Dr. Salm,

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.

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Kind regards,

Giancarlo Condello, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional): NA

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: All comments have been addressed

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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: Yes

Reviewer #2: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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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: (No Response)

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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: (No Response)

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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: The authors carefully responded to each of the reviewers' comments and clarity of the manuscript further improved. I very much appreciate the modifications and enjoyed reading the revised manuscript. I believe that the only thing I am missing is that although the authors carefully described how optimal propulsion biomechanics include long and smooth strokes, there could be a couple of words added to the discussion stating that this is not only associated with efficiency but also with reduced shoulder loads and therefore is included in the guidelines to preserve shoulder health in wheelchair users. Changes to propelling with a smaller push angle have also been observed as a compensation mechanism in response to fatiguing propulsion in wheelchair users. It therefore appears that when pushing the system (either through fatigue or dual-task performance), wheelchair users compensate for the 'easier' propulsion style, yet this may increase demands on shoulder and potentially lead to injury. Thank you for your work.

Reviewer #2: (No Response)

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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: Yes:  Fransiska M Bossuyt

Reviewer #2: No

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