PONE-D-24-45706Mediation and moderation analysis of the association between physical capability and quality of life among stroke patientsPLOS ONE

Dear Dr. Yao,

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.

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Diphale Joyce Mothabeng, PhD

Academic Editor

PLOS ONE

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“The work was supported by the Major Science and Technology Project of Yunnan Province (Grant numbers[2018zf016]), Rehabilitaion Clinical Medical Centre of Yunnan Province (Grant numbers[zx2019-04-02]), National Key Research and Development Program (Grant numbers[2018YFC2002301]), and Jiajie Expert Workstation of Yunnan Province (Grant numbers[2019IC034]), and Kunming Medical University Postgraduate Innovation Fund (Grant numbers[2022B11]).”

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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: No

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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 manuscript was well written. There are a few minor corrections to be made. These are in the track-changed document attached.

I t will be great to discuss how stroke affects the qukity of life of stroke survivors. Also, the results on BRS, MiniBest, QoL, BSE abd depresion has to be pesented first before the correlations.

Reviewer #2: This is a very interesting article, in that it provides sound scientific evidence of suspicions that we all had regarding stroke patients. The researchers are commended for the work that was done.

I only have minor suggestions to improve the readability of the information provided and you will see that the majority of the comments are language/editing related - it might be advisable to consider using a language editor to review the paper as well:

1) Throughout the document, 'capacity' and 'capability' are used interchangeably. Although these words do have the same meaning, it will be easier to read and process the information if the same term is used throughout (I would recommend using 'capability' as indicated in the title). If the researchers did not intend to use the words as synonyms, it would be helpful to include a definition or description of the difference between the terms in the introduction section.

2) In the abstract, under the results heading there is a ' before physical capability (last sentence of the results section). Please either remove the ' or complete the statement by adding a ' after depressive symptoms.

3) In the introduction section, the first sentence is a bit difficult to read because of the punctuations used, my suggestion would be to change the sentence to: Stroke is a primary cause of long-term neurological disability, with >80 million stroke survivors globally in 2016. (so remove the ; and change worldwide to globally to enhance the flow of the sentence).

4) In the second paragraph in the introduction (balance), the second sentence is a bit unclear (i.e., is the sedentary lifestyle a result of the stroke or as a result of the fear of falling)? Please rephrase for clarity.

5) In the balance paragraph, in the sentence after the ABC questionnaire, please change it to it is (i.e., it is also called)

6) Please revise the sentence in the balance paragraph (after reference nr 17) for ease of reading, my suggestion would be: Studies in the last few decades have produced fairly convergent results, indicating that higher balance self-efficacy is linked to better QOL of stroke patients.

7) In the sentence after reference 21, please remove the word 'here'.

8) In the first sentence on page 11 (after reference nr 24), please change to 'One research study'. In the following sentence, please change contributes to contribute.

9) In the introductory paragraph, regarding hypertension, please elaborate a bit more in terms of what you mean by 'significantly affecting daily lives' - is this activities of daily living?

10) At the conclusion of the introduction section, the information is a bit confusing (although I do see that you merged hypothesis one and two and reported it as one) - but this can be very confusing. I would recommend that you either adhere to the two hypothesis (as indicated at the end of the introduction section throughout) or that you write out all three (without merging the described hypothesis 1 and 2). Which ever you decide, please remember to adapt the abstract accordingly.

11) In figure 1, it would be nice to add either colour or a bit more information, so that it is clear which factors are hypothesised to be mediators and which factors are moderators (to align more clearly with the written information).

12) Regarding the exclusion criteria, please be a bit more specific regarding 'several mental disorders' - are these disorders classified on the DSM and how many were considered to be too many (for example, if a patient had anxiety and depression were they excluded, or were more than 2 diagnoses required for exclusion?). Were previous disability excluded as well? For example, if the patient had an amputation / severe orthopaedic condition? (as these factors may influence the results of the study)

13) Figure 2 does not really indicate any additional information from what was provided in the text and the researchers can consider omitting it from the manuscript.

14) In the Procedure section (under the Methods heading) I referred to the referenced paper regarding quality controls, but it is not clear what the researchers are referring to - i.e., what quality controls were used? (This information is from the referenced study: Subsequently, 10 hospitals were invited to participate in relevant training programs every 3 months, and two trained investigators made irregular visits to different hospitals to collect information and conduct quality control. - is this what the researchers are referring to? Because it is not a lot of information, it might be useful to write it out in the current study (under review).

15) In the results section, please revise the second sentence, I suspect it is supposed to read: The majority of participants had an ischemic stroke, while hemorrhagic- and other strokes were reported in 101 and 13 patients respectively.

16) Please clarify whether left stroke and right stroke refers to left/right hemiplegia/paresis or left or right cerebral involvement.

17) Just for noting - I found the path analysis very interesting and Figure 3 really assisted with interpreting and understanding all the information (which can sometimes be a bit overwhelming)

18) I think your interpretation of the diabetes/gender effect may be a bit harsh, i.e., that your hypothesis was rejected. I would recommend that you add that although the results from your study didn't support your hypothesis, the smaller (significantly so?) number of females (compared to males) and the small number of patients with diabetes may have influenced the results.

19) In the discussion section, in the first sentence of the second paragraph (however, we found no...) please elaborate the sentence a bit more so that the 'relationship' you are referring to is clear.

20) Discussion section: When using in-text references, you don't have to include the initials (so it will become Sok et al.)

21) Please reference the sentence on page 17, i.e., 'it could be that antidepressant therapy interferes with blood pressure control in hypertension patients' - alternatively, if this is not a proven fact, indicate it (for example, the possibility exists that antidepressant therapy interferes with blood pressure control in hypertensive patients, but further research on the topic is warranted).

22) The sentence directly after the one referred to in comment 21 needs revision - so that the link between postmenopausal women and the study becomes clear (for example: additionally, a recent study showed that increased walking (physical) activity lowers hypertension risk in postmenopausal women [52]. Our study also indicated that physical activity positively influences hypertension risk, even in a mixed-gender population.

23) The final sentence of the discussion needs to be preceded by a sentence regarding balance so that the linkage becomes clear.

24) Throughout the discussion section OR (alternatively) in the limitations section, the researchers should make some recommendations for future research (either to say how limitations can be minimised in future research, or recommendation for future research based on the findings of the study.

25) Please ensure the correct tense is used in the conclusion paragraph (the study has been conducted, so the section should be in the past tense).

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Reviewer #1: Yes:  Tawwagidu Mohammed

Reviewer #2: Yes:  Maria Elizabeth Cochrane

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Attachments

Attachment

Submitted filename: PONE-D-24-45706_reviewer.pdf

PONE-D-24-45706R1Mediation and moderation analysis of the association between physical capability and quality of life among stroke patientsPLOS ONE

Dear Dr. Yao,

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.

==============================

Your manuscript, entitled "Mediation and moderation analysis of the association between physical capability and quality of life among stroke patients ", has been reviewed. Your efforts to revise the manuscript are appreciated. However, the peer review process continues because Reviewer 1 has a few additional comments that the author should address. Please find the reviewer's comments below.

==============================

Please submit your revised manuscript by Mar 09 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,

Tanja Grubić Kezele, Ph.D., M.D.

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.

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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: 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: Yes

**********

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

Reviewer #1: Yes

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: Well done on the manuscript. There are a few comments attached to address to further improve the work.

Reviewer #2: Thank you very much for addressing the comments thoroughly. The manuscript is ready for publication.

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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:  Tawagidu Mohammed

Reviewer #2: No

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[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.

Attachments

Attachment

Submitted filename: PONE-D-24-45706_R1- reviewed.pdf

Attachment

Submitted filename: COMMENTS.docx

Mediation and moderation analysis of the association between physical capability and quality of life among stroke patients

PONE-D-24-45706R2

Dear Dr. Yao,

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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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,

Tanja Grubić Kezele, Ph.D., M.D.

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: Yes

**********

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

Reviewer #1: 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

**********

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

**********

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: Well done on improving the manuscript. All comments raised in the previous review have been adequately addressed

**********

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:  Tawagidu Mohammed

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