The Influence of Personality Type on Patient Outcome Measures and Therapeutic Alliance in Patients with Low Back Pain

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this manuscript. I believe it is a timely topic in individuals with LBP and I commend the authors for their writing. It is one of the better written manuscripts I have reviewed. I think the introductions and discussion sections are solid with the necessary background information leading to the purpose statement in the introduction, and the placement of the results within the current literature in the discussion, respectively. 

I have one minor suggestion for sentence structure, where I think some words may be missing. This is in the results section lines 212-220, specifically the second sentence that starts with ODI and TSK (0.462)...

My biggest questions for the authors are two fold:

1. What type of LBP was included in this study? The inclusion criteria state individuals with LBP. Since LBP is extremely heterogenous, are their more details the authors can provide such as the duration of symptoms or if radicular symptoms were present? If this is not possible given the date presented, I would suggest this is added as a limitation to the manuscript as it is my thought that different cohorts of individuals with LBP, might demonstrate different results. 

2. Can the authors provide any information on how the sample size for the therapists and patients was decided on? 

Author Response

We would like to thank the reviewer for their time and efforts in review of our manuscript.  We found the comments to be very helpful and will help to strengthen the manuscript.  We have addressed each of the concerns point by point below. 

REVIEWER 1

Thank you for the opportunity to review this manuscript. I believe it is a timely topic in individuals with LBP and I commend the authors for their writing. It is one of the better written manuscripts I have reviewed.

--We would like to thank you for the kind words and appreciate your time and effort in review of our manuscript.

I think the introductions and discussion sections are solid with the necessary background information leading to the purpose statement in the introduction, and the placement of the results within the current literature in the discussion, respectively.

--Again, we thank you for the kind words. 

I have one minor suggestion for sentence structure, where I think some words may be missing. This is in the results section lines 212-220, specifically the second sentence that starts with ODI and TSK (0.462)...

--Thank you for pointing this out.  We have edits the sentence to improve readability.

My biggest questions for the authors are two fold:

1. What type of LBP was included in this study? The inclusion criteria state individuals with LBP. Since LBP is extremely heterogenous, are their more details the authors can provide such as the duration of symptoms or if radicular symptoms were present?

--Unfortunately, we did not identify subcategories of individuals with low back pain.  The reviewer is correct as the heterogeneous nature of the sample reduces the ability to generalize.

If this is not possible given the date presented, I would suggest this is added as a limitation to the manuscript as it is my thought that different cohorts of individuals with LBP, might demonstrate different results.

--The reviewer identifies a good point, and we agree. We have added this as a limitation to the manuscript. 

2. Can the authors provide any information on how the sample size for the therapists and patients was decided on?

--Thank you for pointing this out.  Sample size was based on convenience.  We have edited the manuscript to reflect how sample size was determined.

Reviewer 2 Report

Dear Authors, 

It is my pleasure to have the opportunity to review the work titled "The Influence of Personality Type on Patient Outcomes and Therapeutic Alliance in Patients with Low Back Pain." I have thoroughly examined the topic to approach it without preconceptions and provide valuable scientific comments to enhance your work. As a reviewer, I have focused on specific aspects such as the topic, title, and results, aiming to suggest improvements for scientific rigor, cohesiveness in the introduction, and the accessibility of the topic to non-scientific readers.

Based on my understanding and knowledge, I have provided the following comments, which I hope you will find helpful and consider:

1. In lines 42-46, I suggest that you first define personality and then provide its predictive descriptors.

2. In lines 76-77, is the first sentence from the same citation as the second sentence? If not, please provide a citation for referencing the sentence.

3. In line 129, it would be helpful to provide a description of Qualtrics, such as "Qualtrics, a survey software platform," to clarify its nature.

4. In lines 146-147, you have already mentioned what EPI stands for, so it is unnecessary to repeat it twice more.

5. In Table 1 and Table 2, I recommend keeping the same order for consistency. For example, if you mention PT first in Table 1, follow the same order in Table 2. Additionally, it would be better to use the same descriptive statistics format across both tables. If you use "Mean (SD)" for demographics in one table, use the same format in the other. Similarly, if you use percentages, be consistent in both tables.

6. In Tables 3 and 5, you can provide the corresponding percentages (%) next to each number to enhance clarity.

7. You have referred to "outcome," but it seems only to denote a correlation rather than a direct result of these correlations. It would be helpful to specify which outcomes you are referring to.

8. In lines 240-241, you mention a "greater level of improvement," but whether participants filled out the questionnaires before and after the therapies or just once is unclear. It is important to clarify this to establish if any changes were observed. Therefore, using the term "outcomes" may not be appropriate for this type of research and its results. Consider revising the title to something like "associated factors" or "correlational study."

9. In line 242, you state that patients "may perceive their progress," but I couldn't find any mention of pre-post-tests to observe their progress. The same applies to satisfaction and other factors.

10. In line 261, you mention that "based on the description, it is clear." This statement requires more support, such as evidence from other literature or strong evidence from multiple correlational studies. Studies like (Moskowitz et al., 2013), (Dopelt et al., 2014), and (Robinson et al., 2017) present differing ideas, and the statement "it is clear" cannot be made without considering these contradictory results.

11. In line 287, you mention the term "formal education" in Tables 3 and 5, but it is unclear what this term refers to. No information is provided in the tables, or it may be indirectly stated. Please clarify this term.

Furthermore, the study does not specify whether participants were aware of the study's purpose or if they received any incentives for participating, such as discounts or extra therapy sessions. This information should be addressed.

In conclusion, while the study is interesting, the title and procedures do not align. As a reviewer, I found the conclusion section confusing due to some sentences that contradict previous research, as I mentioned earlier. Additionally, the study lacks a clear "outcome" since it is a simple correlational study. Secondly, assuming it is a correlational study, the topic itself needs to be more specific. For example, you mention "American-Indian" and then "Other" without specifying what "Other" means. Moreover, it is important to consider that most people in the area are "Hispanic", with a rate of 27.1% (ref. Census.org). This taxonomy of demographics does not provide sufficient context, and I suggest redesigning the table accordingly. The tables must also follow a hierarchical structure, such as organizing pain levels.

Finally, I appreciate the authors' work and collaboration, and I hope these considerations will help improve their work.

Kind regards,

The English proficiency is commendable, devoid of jargon. As previously stated, the "formal education" concept lacks clarity for readers and myself.

Author Response

REVIEWER 2

We would like to thank the reviewer for their time and efforts in review of our manuscript.  We found the comments to be very helpful and will help to strengthen the manuscript.  We have addressed each of the concerns point by point below. 

1. In lines 42-46, I suggest that you first define personality and then provide its predictive descriptors.

--Thank you. This point is well taken and we have edited the manuscript to define personality prior to providing predictive descriptors.

2. In lines 76-77, is the first sentence from the same citation as the second sentence? If not, please provide a citation for referencing the sentence.

--The authors agree that this isn’t clear for the reader.  It is the same citation however for clarity we have included the in text citation after the first sentence. 

3. In line 129, it would be helpful to provide a description of Qualtrics, such as "Qualtrics, a survey software platform," to clarify its nature.

--Thank you for the suggestion.  We have edited this sentence to help provide additional description for Qualtrics. 

4. In lines 146-147, you have already mentioned what EPI stands for, so it is unnecessary to repeat it twice more.

--Thank you for pointing this out.  We have omitted the spelling out of EPI for brevity and consistency.

5. In Table 1 and Table 2, I recommend keeping the same order for consistency. For example, if you mention PT first in Table 1, follow the same order in Table 2. Additionally, it would be better to use the same descriptive statistics format across both tables. If you use "Mean (SD)" for demographics in one table, use the same format in the other. Similarly, if you use percentages, be consistent in both tables.

--The authors agree and we have edited Table 1 and Table 2 to improve consistency.

6. In Tables 3 and 5, you can provide the corresponding percentages (%) next to each number to enhance clarity.

--Thank you for the suggestion.  We agree and feel this would be a much clearer way to present the data. We have edited tables 3 and 5 as requested.

7. You have referred to "outcome," but it seems only to denote a correlation rather than a direct result of these correlations. It would be helpful to specify which outcomes you are referring to.

--Thank you for pointing this out.  Our reference to “outcome” is specific to outcome measures (i.e. Numeric Pain Rating Scale (NPRS), Oswestry Low Back Pain Disability Questionnaire (ODI), Tampa Scale of Kinesiophobia (TSK), Global Rating of Change (GROC), and Working Alliance Index (WAI).  However, we can see how this may provide some confusion.  We have attempted to clarify in text a specific reference to outcome measures.  We hope this helps improve clarity however we are more than happy to make further edits should the reviewer feel there is a better way to approach this.

8. In lines 240-241, you mention a "greater level of improvement," but whether participants filled out the questionnaires before and after the therapies or just once is unclear. It is important to clarify this to establish if any changes were observed. Therefore, using the term "outcomes" may not be appropriate for this type of research and its results. Consider revising the title to something like "associated factors" or "correlational study."

--This is very insightful and we sincerely appreciate the reviewer comment.  I don’t this we were clear in differentiating a given “outcome” vs. use of outcome measures.  To enhance clarity we included “self reported outcome measures” where appropriate.  In addition, we edited the title to read, “ The influence of personality type of patient outcome measures and therapeutic alliance in patients with low back pain”  We hope that this provides better context for

9. In line 242, you state that patients "may perceive their progress," but I couldn't find any mention of pre-post-tests to observe their progress. The same applies to satisfaction and other factors.

--Thank you for pointing this out.  We agree that this may provide confusion.  For clarity we edited the sentence to reflect the current status of their condition rather than a change in their condition.  We hope this improves the clarity.

10. In line 261, you mention that "based on the description, it is clear." This statement requires more support, such as evidence from other literature or strong evidence from multiple correlational studies. Studies like (Moskowitz et al., 2013), (Dopelt et al., 2014), and (Robinson et al., 2017) present differing ideas, and the statement "it is clear" cannot be made without considering these contradictory results.

--Thank you for this suggestion. We agree that citations are necessary when making a statement such as this.  We have included several citation that we feel help to support this statement.

11. In line 287, you mention the term "formal education" in Tables 3 and 5, but it is unclear what this term refers to. No information is provided in the tables, or it may be indirectly stated. Please clarify this term.

--Thank you.  This does seem to be a bit confusing.  This statement was in reference to instruction provided during treatment sessions.  We have edited this sentence to more accurately reflect the intent.

Additional Points

The study does not specify whether participants were aware of the study's purpose or if they received any incentives for participating, such as discounts or extra therapy sessions. This information should be addressed.

--Thank you.  We have included this information in as part of the methods section.

In conclusion, while the study is interesting, the title and procedures do not align.

--We agree and appreciate the reviewers insightful comments. We have edited the title to better reflect the actual research methodology.

Additionally, the study lacks a clear "outcome" since it is a simple correlational study.

--We agree and believe the term “outcome” and “patient reported outcome measure” may have been confusing for the reader.  We have attempted to address this disparity as stated previously to provide better clarity.

For example, you mention "American-Indian" and then "Other" without specifying what "Other" means.  Moreover, it is important to consider that most people in the area are "Hispanic", with a rate of 27.1% (ref. Census.org). This taxonomy of demographics does not provide sufficient context, and I suggest redesigning the table accordingly.

--Thank you we have edited the tables and included a note to clarify “other”.  We hope this addresses the reviewer concern.

Round 2

Reviewer 2 Report

Dear authors,

I appreciate your feedback on the updates made to improve the clarity and coherence of the content. The revisions have enhanced the resonance and intelligibility considerably. I tried to reread the whole text “As a reader without subject-matter expertise,”-aiming to target a larger number of readers, and I found the current version much more accessible and straightforward to comprehend. The tables and data are presented lucidly. However, two minor issues in the new version need to be addressed:

Line 46 - The citation order requires updating, as reference (5) precedes reference (4), while reference (4) has not been previously mentioned.

Lines 310-311 - The sentence "we dit not specify a specific type..." is unclear. I suggest rephrasing or providing additional context for comprehension.

Author Response

July 28^th, 2023

We would like to thank the reviewer for their time and efforts in review of our revision.   The comments were very helpful.  We have addressed each of the points below.

REVIEWER 2

I appreciate your feedback on the updates made to improve the clarity and coherence of the content. The revisions have enhanced the resonance and intelligibility considerably. I tried to reread the whole text “As a reader without subject-matter expertise,”-aiming to target a larger number of readers, and I found the current version much more accessible and straightforward to comprehend. The tables and data are presented lucidly. However, two minor issues in the new version need to be addressed:

--Thank you for the kind words and we sincerely appreciate your constructive feedback.  We agree that the suggestions improved the manuscript significantly. 

Line 46 - The citation order requires updating, as reference (5) precedes reference (4), while reference (4) has not been previously mentioned.

--Thank you for pointing this out.  We have corrected the citation order.

Lines 310-311 - The sentence "we dit not specify a specific type..." is unclear. I suggest rephrasing or providing additional context for comprehension.

--We apologize. This should have been identified prior to resubmission.  However, we appreciate you pointing it out.  We have edited the sentence so it is more coherent.