The effects of visual stimulation on the cortical activity of brainstem stroke dysphagia patients: A functional near-infrared spectroscopy study

Dandan Zhao; Yancun Li; Keyi Ning; Bingjie Zou; Bin Wang; Libo Li; Qiaojun Zhang; Yanping Hui

doi:10.1371/journal.pone.0325510

Peer Review History

Original SubmissionOctober 14, 2024
14 Oct 2024 Author Response https://doi.org/10.1371/journal.pone.0325510.r001
18 Mar 2025 Decision Letter - Shashank Shekhar, Editor PONE-D-24-45819The effects of visual stimulation on the cortical activity of brainstem stroke dysphagia patients: A functional near-infrared spectroscopy studyPLOS ONE Dear Dr. Hui, 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.There are minor comments. Hopefully the authors will easily take care of the issues raised by reviewers. Please submit your revised manuscript by May 02 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 . 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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: Thank you for submitting your manuscript. The aims of the paper are articulated. However, the design has certain flaws that need addressing, as detailed below: 1. The Visual Analog Scale (VAS) is generally used for pain assessment. Is it appropriate to assess dysphagia? 2. The patients' mini-mental state examination (MMSE) was≥17 points. Should people with different academic qualifications be distinguished? 3. The discussion section needs to be optimised in detail. Reviewer #2: 1) The abstract does not highlight the focus on functional connections between different brain ROIs in the methods section. 2) The conclusion states - "The overall strength of functional connections was decreased, while the ROI between different brain areas increased." - this is quite ambiguous, and possibly misleading. I am assuming that it was meant to imply that the functional connections between specific ROIs in the brain are increased. 3) Between the patients selected who suffered a brainstem stroke and healthy patients, was there a significant difference in the resting HbO2 levels? 3) similarly, is there any clinical data to rule out the possibility of pre-existing conditions in brainstem stroke patients which may have impacted the delta HbO2 further? - such as smoking, COPD, diabetes, peripheral artery disease, carotid or vertebral artery stenosis? Additionally, it may be helpful to give references to help negate or quantify the effect of these disorders on the levels of HbO2. ****** 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". 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Revision 1
14 Apr 2025 Author Response No.: PONE-D-24-45819R1 Title: The effects of visual stimulation on the cortical activity of brainstem stroke dysphagia patients: A functional near-infrared spectroscopy study First author: Dr. Dandan Zhao Corresponding author: Prof. Yanping Hui Dear editor and reviewers: The authors thank you for the comments concerning our manuscript. The comments are all valuable and helpful for us to revise and improve the manuscript. We have revised the manuscript seriously according to the comments and suggestions of the reviewers. In the following we specify changes made in the manuscript, and reply point-by-point to the reviewers’ comments. Thanks! Prof. Yanping Hui Response to editor� Major Comments: Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response 1: Thank you very much for your reminding. In an effort to comply with PLOS One's publishing requirements, we have modified the manuscript's format in accordance with PLOS One's template. Changes were made as follows: The first page of the text had the title, author, and unit; Make use of the appropriate typeface and title format; After the first paragraph that is cited, put the title of each graph; Place the table immediately below the paragraph that was cited first; Changed the format of citations and supporting information in the manuscript; Each researcher's contributions are described at the conclusion of the study; Remove the financial disclosure statement from the text. Comment 2�Thank you for submitting the above manuscript to PLOS ONE. During our internal evaluation of the manuscript, we found significant text overlap between your submission and previous work in the [introduction, conclusion, etc.]. We would like to make you aware that copying extracts from previous publications, especially outside the methods section, word-for-word is unacceptable. In addition, the reproduction of text from published reports has implications for the copyright that may apply to the publications. Please revise the manuscript to rephrase the duplicated text, cite your sources, and provide details as to how the current manuscript advances on previous work. Please note that further consideration is dependent on the submission of a manuscript that addresses these concerns about the overlap in text with published work. Response 2�Thank you for your feedback about the overlap in our articles. We sincerely apologize for this oversight and have reworded some of the overlapping parts of the introduction, methods, discussions and conclusions. The complete text repetition rate is less than 20%, according to the Turntin and iThenticate reviews, and the citations have been suitably appended to the earlier work. We further extend the introduction to concentrate on the pre-oral period of swallowing in contrast to earlier PSD research. Additionally, the use of near-infrared spectroscopy instruments allows individuals to collect brain function data under natural conditions to meet the needs of food visual stimulation tasks. In the discussion section, we emphasize the connection between pre-oral swallowing and cognition and highlight the benefits of the fNIRS block design in this investigation. At the same time, we demonstrate that fNIRS brain function changes may be used to predict swallowing features and risk, and can be employed as a supplementary method of clinical diagnosis and therapy, particularly given the existing challenges in measuring preoral function. Furthermore, our research established a theoretical basis for the use of food visual stimulation as a therapeutic preoral therapy method. Comment 3: Thank you for stating the following in the Acknowledgments Section of your manuscript: “This work was funded by National Natural Science Foundation of China (81902291) and Natural Science Foundation of Shaanxi Province (2024JC-YBMS-656). We thank our co-workers at the The Second Affiliated Hospital of Xi 'an Jiaotong University.” We note that you have provided additional information within the Acknowledgements Section that is not currently declared in your Funding Statement. Please note that funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: “The author(s) received no specific funding for this work.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. Response 3�Thanks for your careful reading and helpful comments on our manuscript, we have removed the text related to the grant from the manuscript. We would like to update the funding statement for this study as follows: “This research has received two grants: National Natural Science Foundation of China (81902291) and Natural Science Foundation of Shaanxi Province (2024JC-YBMS-656).” I included this section in the cover letter as well. Comment 4: When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. Response 4�Thank you for your reminding. All the data in this study have been reflected in the manuscript and supporting information files. Comment 5: We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. Response 5�We notice this problem and sincerely apologize for any trouble that this error may have caused you. We will ensure that the correct grant numbers is provided for the awards in the "Funding Information" section when we resubmit. Comment 6: Thank you for stating the following financial disclosure: “The author(s) received no specific funding for this work.” At this time, please address the following queries: a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution. b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” c) If any authors received a salary from any of your funders, please state which authors and which funders. d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. Response 6�I apologize for any confusion I may have caused you. I will answer the following questions and explain them in the submission letter. a) The research was funded by the National Natural Science Foundation of China (81902291) and the Natural Science Foundation of Shaanxi Province (2024JC-YBMS-656). b) Funders have no role in research design, data collection and analysis, decision to publish, or preparation of the manuscript. c)None d) This research was supported by the National Natural Science Foundation of China (81902291) and the Natural Science Foundation of Shaanxi Province (2024JC-YBMS-656). Comment 7: 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. Response 7: Thank you for reminding us. We have checked the references one by one to make sure they are complete and correct. Response to reviewers� Reviewer #1� General comments: The aims of the paper are articulated. However, the design has certain flaws that need addressing Response: Thanks to the reviewer for approving our idea. We will be very happy to edit the text further and answer your query, based on helpful comments from you. Comments 1: The Visual Analog Scale (VAS) is generally used for pain assessment. Is it appropriate to assess dysphagia? Thank you very much for your questions about our manuscript. The Visual Analog Scale (VAS) was used in this research to evaluate the participants' appetites. We selected this scale since prior research on eating disorders utilized VAS scale to measure the extent of participants' food cravings (Adi Ziv., 2020), and VAS scale was also used to measure the demand for drugs in drug addiction and associated research (Xiao Lin & Jiahui Deng & Kai Yuan., 2021). I thought the reason you were confused was because I did not fully describe the purpose of the VAS scale in the method section. Added modifications have been made to the original manuscript (P 7, line 132-134 from the top). Comments 2: The patients' mini-mental state examination (MMSE) was≥17 points. Should people with different academic qualifications be distinguished? Response 2: We really appreciate you bringing up our inadequacies. The patient's MMSE score was as follows when we included them: illiteracy >17; primary school >20 points; middle school >23 points; and university >24 points, which could cooperate with the completion of rehabilitation treatment and evaluation. Following this, the median MMSE for the patient group was 28 and for the healthy group was 30 (refer to Table 1), and all of the individuals we recruited had MMSE scores more than 24 points. However, the inclusion criteria were not explained in detail, and the inclusion criteria of this part were refined and supplemented in the original text. (P 6, line 118-120 from the top). We will also be careful to prevent such issues in the future. Thank you again for your careful review. Comments 3: The discussion section needs to be optimised in detail. Response 3: Thank you very much for your suggestion, we have reorganized the paragraph structure of the discussion section to make its logic clearer. In addition, we expanded the discussion section's content, explained the significance of the results in detail, fully discussed the similarities and differences with existing studies. Furthermore, we clarified the study's innovation points, limitations, and future development. (P 15, line 278-384 from the top) Reviewer #2� Comments 1: The abstract does not highlight the focus on functional connections between different brain ROIs in the methods section. Response 1: Thanks to your suggestion, we have supplemented the technical details of functional connections between different brain ROIs in the methods section of the abstract� The fNIRS was used to assess the functional connection strength of global and ROIs brain regions at rest, as well as the mean change in oxygenated hemoglobin concentration (ΔHbO2) during the food visual stimulation task in both groups. (P 2, line 29-31 from the top) The selection of the ROI brain area is available in the Methods section of the text. (P 7, line 151-156 from the top) Comments 2: The conclusion states - "The overall strength of functional connections was decreased, while the ROI between different brain areas increased." - this is quite ambiguous, and possibly misleading. I am assuming that it was meant to imply that the functional connections between specific ROIs in the brain are increased. Response 2: I am very sorry for the confusion caused to you. In the specific analysis of the study, the overall functional connectivity of patients with swallowing disorder after brain stem stroke decreased, while the functional connectivity between specific ROIs brain regions increased, as shown in Table 2. We also reviewed some literatures related to fNIRS and fMRI to explain this result. Xu et al.'s study indicated that the average strength of functional brain network connections was higher in healthy subjects than in patients. However, intra-hemisphere or interhemisphere connections, as well as the functional connection map, were more sparse in the stroke group than in the control group (Gongcheng Xu., 2024). But according to our analysis of the literature, Cai et al. contrasted various FC (functional connectivity) patterns amongst individuals with mild, moderate, and severe hemiplegia. According to research, individuals with severe hemiplegia have strong connection in certain brain areas, which may indicate a compensating mechanism or alternative motor network rearrangement techniques (Guiyuan Cai & Jiayue Xu & Cailing Zhang & Junbo Jiang., 2024). Quinlan E B et al. discovered that patients with more severe injuries had higher iM1 FC in CPMCS after three weeks of standardized robotic therapy, but patients with less severe injuries showed the inverse connection (Erin Burke Quinlan., 2018). These findings may imply that various brain areas are necessary for motor recovery in stroke patients and that additional brain regions may be recruited for functional compensation, which is shown in improved local functional connectivity. Comments 3: Between the patients selected who suffered a brainstem stroke and healthy patients, was there a significant difference in the resting HbO2 levels? Response 3: We greatly admire your sensitivity to mixed signals during fNIRS testing. When detecting the cerebral cortex, fNIRS also detects the outer tissue layer of the brain to a certain extent. Variations in oxygenation and blood flow in non-brain tissues may impact fNIRS signaling and cause interference with measurement data. Additionally, brain hemodynamics are also impacted by systemic physiological changes. Examples include: (1) variations in blood pressure, (2) variations in the partial pressure of carbon dioxide (PaCO2), (3) variations in heart rate and vascular tone brought on by interactions between the sympathetic and autonomic nervous systems, and (4) variations in blood flow and oxygenation brought on by head movements, clenching, or raising of the eyebrows. Firstly, we used the long-short source detector separation (SDS) strategy to detect only changes related to brain activity, reducing the confounding effects of strong hemodynamic changes occurring in the extracerebral tissues, and eliminating the possible effects of microcirculation abnormalities on signals caused by the above diseases. At the same time, the Modified Beer-Lambert Law (MBLL) is used to eliminate or reduce the signal deviation caused by non-target factors (such as tissue scattering, instrument noise, physiological interference, other absorbent substances, etc.). In addition, we also strictly followed the enrollment criteria when we included patients. All the included patients with swallowing disorder after brainstem stroke were in stable condition and had no history of serious peripheral artery disease, carotid artery or vertebral artery stenosis, so as to control Attachments Attachment Submitted filename: Response to Reviewers_2025.4.14.docx https://doi.org/10.1371/journal.pone.0325510.r003
15 May 2025 Decision Letter - Shashank Shekhar, Editor The effects of visual stimulation on the cortical activity of brainstem stroke dysphagia patients: A functional near-infrared spectroscopy study PONE-D-24-45819R1 Dear Dr. Hui, 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. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. 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 #2: Appreciate the clarifications for the points raised, especially about resting HbO2 levels being accounted for in both patient groups when performing the fNIRS. ****** 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 #2: No ******** https://doi.org/10.1371/journal.pone.0325510.r004
Formally Accepted
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