Experiences of SENSory Relearning of the UPPer Limb (SENSUPP) after Stroke and Perceived Effects: A Qualitative Study

Round 1

Reviewer 1 Report

Here are some suggestions for improvements, which mainly directly increase the study's importance and preferable the way the discussion and conclusions are presented. 

To increase why the study is conducted, can you describe how many persons are affected yearly. The statistics can be presented on a national basis or an international basis. See, e.g., SCB or WHO to get interesting facts. 

Another figure of interest is how often is sensory relearning used? Such a figure would add to the problem statement. 

How is the evaluation related to the training protocol?

What is the difference between experience and perception?

You decided the number of respondents based on quantitative research design, and I am interested in your view on empirical saturation. 

How did the extended time affect the training schema and the interviews?

The discussion doesn't give that much. If you focus on giving something to the practitioner community, I would suggest that you detail the perceptions into guidelines. You can give something more interesting than overall perceptions and experiences from some respondents. 

 

Author Response

Response to Reviewer 1 Comments

Comments and Suggestions for Authors

Here are some suggestions for improvements, which mainly directly increase the study's importance and preferable the way the discussion and conclusions are presented.

 

Point 1: To increase why the study is conducted, can you describe how many persons are affected yearly. The statistics can be presented on a national basis or an international basis. See, e.g., SCB or WHO to get interesting facts.

Response 1: Thank you for this comment. In the Introduction section, we have now included how many persons that suffer a stroke every year in Sweden and the prevalence of sensory impairments of the upper limb in the chronic phase after stroke.

 

Point 2: Another figure of interest is how often is sensory relearning used? Such a figure would add to the problem statement.

Response 2: We agree with the reviewer that this information would be interesting to add in the manuscript. However, we have not found any study that has reported how often sensory relearning is used in stroke rehabilitation. In the literature, it is described that specific sensory training is lacking in rehabilitation despite that around 50% of people suffering a stroke have sensory impairments in the upper limb, which could negatively impact motor recovery and the ability to use the hand in daily life. Furthermore, when it comes to combining sensory and motor training only few studies have described this approach in the literature, which is addressed in the Introduction section.

 

Point 3: How is the evaluation related to the training protocol?

Response 3: The participants were asked how they experienced the SENSUPP protocol and possible effects. Thus, the questions in the interview guide were related to the training protocol and its various parts as being described under 2.3 A brief description of the SENSUPP protocol.

 

Point 4: What is the difference between experience and perception?

Response 4: Thanks for this comment, we understand that confusion may arise when using both terms, especially in the title of the manuscript. We have therefore reformulated the title to ’Experiences of SENSory relearning of the UPPer limb (SENSUPP) after stroke and perceived effects: a qualitative study’. In the manuscript, both terms are however used in order to vary the text.  

 

Point 5: You decided the number of respondents based on quantitative research design, and I am interested in your view on empirical saturation.

Response 5: The group consists of the 15 participants who were randomized to sensory relearning in the pilot RCT, and all these persons were interviewed in the present study which is a strength. This has been raised in the Discussion section under the subheading ‘4.1. Methodological considerations’. When it comes to saturation, this aspect is often considered in Grounded Theory but not when content analysis is used. In papers were content analysis is applied 10 to 15 participants are usually considered sufficient. Based on our research questions, we are convinced that we have obtained a wide and rich material from the 15 participants.

 

Point 6: How did the extended time affect the training schema and the interviews?

Response 6: The participants had no structured training after the 5 weeks of sensory relearning and 3-month follow-up. One limitation may be that the participants had difficulties to recall their experiences of the training after 3 months. However, based on the interviews, few participants expressed difficulties in remembering how they experienced the training, even though someone mentioned difficulties in remembering specific training elements in more detail. We have addressed this under the heading “4.1 Methodological consideration” in the manuscript.

 

Point 7: The discussion doesn't give that much. If you focus on giving something to the practitioner community, I would suggest that you detail the perceptions into guidelines. You can give something more interesting than overall perceptions and experiences from some respondents.

Response 7: We agree with the reviewer, thank you for this important comment.  Several parts of the Discussion section have now been rewritten in order to focus more clearly on the benefits of our study for clinicians and researchers.

Reviewer 2 Report

Review of manuscript -Manuscript ID: ijerph-1617635

 

The research presented in the reviewed work is a qualitative research. It assessed how people with sensorimotor impairment of the affected upper limb after chronic stroke perceived a 5-week sensory re-learning program, consisting of both outpatient training, home training, and the effects of the training.

 

The subject of the work is interesting, it encourages you to read the work.

However, I see the following shortcomings at work:

It is not known how patients were recruited for the study and what the inclusion or exclusion criteria were. It is not known what tests were performed for the functional assessment of the participants. Too little data on study participants (the table could be completed). I propose to complete the Materials and methods section. Besides materials and methods, unnecessarily plural. Material and methods would be better.

 

Moreover, the authors consider this work to be a strong point,

they write: "The strong point of this study is that 15 participants differing in age, gender, time from stroke occurrence, and degree of sensorimotor impairment in affected UL were included." When these are the limitations of work. Both the number of participants and their diversity in such a small group are not favorable for the analysis.

It would be good to include more people in future research. Receive therapy and analyze results depending on participants' baseline functional status. Such a note can even be supplemented with the results or supplemented in the study limitation.

 

In summary, I believe that the work should be corrected before deciding to publish.

The work requires corrections before it is allowed to be published.

Author Response

Response to Reviewer 2 Comments 

Comments and Suggestions for Authors

The research presented in the reviewed work is a qualitative research. It assessed how people with sensorimotor impairment of the affected upper limb after chronic stroke perceived a 5-week sensory re-learning program, consisting of both outpatient training, home training, and the effects of the training.

The subject of the work is interesting, it encourages you to read the work. However, I see the following shortcomings at work:

Point 1: It is not known how patients were recruited for the study and what the inclusion or exclusion criteria were. It is not known what tests were performed for the functional assessment of the participants. Too little data on study participants (the table could be completed). I propose to complete the Materials and methods section. Besides materials and methods, unnecessarily plural. Material and methods would be better.

Response 1: Thank you for this comment. We have now added the following information under the subheading ‘Participants’: The 15 participants (10 men and 5 women) who had underwent sensory relearning in the pilot RCT were included in this qualitative study. The participants were recruited to the pilot RCT from a rehabilitation unit at a University hospital or from outpatient health care settings by their treating physiotherapists or occupational therapists. Inclusion criteria for participation were: i) sensory impairments of the UL after stroke (≤5 points in Shape-Texture Identification test, STI^TM); ii) ability to grasp and release a wooden block of 2.5 cm by 2.5 cm in the Box and Block test (BBT); iii) ability to understand oral and written information; iv) 18-80 years of age; v) at least 6 months since stroke onset, and vi) ability to independently walk with or without an assistive device. Exclusion criterion was sensory impairment in the UL due to other diseases than stroke.

We have also added information about some outcome measures used when assessing participants’ sensorimotor impairments in the text and in Table 1. We have also changed the heading to Material and methods.

Point 2: Moreover, the authors consider this work to be a strong point, they write: "The strong point of this study is that 15 participants differing in age, gender, time from stroke occurrence, and degree of sensorimotor impairment in affected UL were included." When these are the limitations of work. Both the number of participants and their diversity in such a small group are not favorable for the analysis.

Response 2: We have now reformulated the sentence in ‘4.1. Methodological considerations’. We have also clarified that in a qualitative study, it is often an advantage that the participants differ regarding gender, age and the degree of disability as there is a greater opportunity to gain a broader and deeper perspective on their perceptions and experiences of e.g. a specific training method.

Point 3: It would be good to include more people in future research. Receive therapy and analyze results depending on participants' baseline functional status. Such a note can even be supplemented with the results or supplemented in the study limitation.

Response 3: We agree with the reviewer that in the development of the training concept “sensory relearning”, it would be valuable to include people with various sensorimotor impairments in the upper limb after stroke to be able to better tailor the training for those who would benefit most from it. We have clarified in the Discussion section that in future studies it would be interesting to include more people with mild to moderate sensory impairments and in an earlier phase after stroke. 

In summary, I believe that the work should be corrected before deciding to publish. The work requires corrections before it is allowed to be published.

Response: All issues that the reviewer has commented have now been considered and corrected in the revised version of the manuscript. We therefore hope that the manuscript now is suitable for publication.

 

Round 2

Reviewer 1 Report

Previous comments are satisfactory revised.