Short-Term Outcome of Rehabilitation Program with Hybrid Assistive Limb after Tendon Lengthening in Patients with Cerebral Palsy

Round 1

Reviewer 1 Report

The authors aimed in the present study to evaluate the impact of a short-term rehabilitation program in young patients affected by cerebral palsy.

The object of the research is relevant and of potential interest for the scientific community and of course for patients affected by CP, however some aspects of the manuscript requires some minor revision  by the authors.

ABSTRACT

The abstract does not contain some essential information.

1. The authors defined "patients with cerebral palsy" as object of their study but considered the age of their participants they could consider to better specify "young participants". This may help the reader to more quickly identify to who are directed the findings of the present study.

2. Lines 29-31, although is understandable the difficulty of representing in few sentences the results of a case series analysis, the description of the results could be improved, the authors may consider to include additional details ?

INTRODUCTION

The introduction provide essential information but covering all the key aspects to support the study's objective and hypothesis.

MATERIALS AND METHODS and RESULTS sections

Both sections include all necessary information and the results section describe the outcomes comprehensively.

DISCUSSION

The discussion section is well written and the authors clearly described the main limitations of the present study.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

The manuscript presents a novel device with the potential to improve gait in patients with cerebral palsy. The text is well-embased, but I have some considerations on the methods and results sections, that may improve the readability and comprehension for the readers.

Did the authors perform any type of statistical analysis? A subsection on this topic should be included in the methods. Since it was not presented and the tables do not signalize statistical differences, it is not possible to know if the interpretation of the results was based on a simple numeric observation or on statistical calculation. Despite the small number of participants, statistical analysis should be considered, to guide the interpretation of the data.

The authors should present a flow diagram to summarize the number of volunteers who completed the assessments, and the reasons for their absence (missing data). 

The authors have mentioned that "Patient 6 could not be evaluated since the patient moved to a different hospital 2 months after the intervention". However, patient 6 has the greater number of HAL7 training days and presents some data from post-HAL after 3 months in table 3.  The flow diagram suggested may clarify some aspects that are hard to follow in the text.

It is not clear if all of the patients could conclude the protocol of 12 sessions using HAL. Since the main objective is to analyze the outcomes of HAL integration into a postoperative rehabilitation program, the authors should be more focused to describe and discuss the findings around the aim of the study.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

This paper is well structured and analyzed. However, as the authors mention limitations, the experiment had fewer participants and lacked a control group. Therefore it is possible that the lower extremity motor ability improvement is an effect of natural postoperative recovery and the role of robot-assisted assisted recovery could not be analyzed.

Author Response

Response to Reviewer ３ Comments

We thank the Reviewer for their thoughtful comments, which have helped us significantly our manuscript.

We agree with the reviewer’s advice.  We also added a paragraph to "4. Discussion" comparing the course of the literature with usual rehabilitation postoperatively and with the incorporation of HAL intervention (Line 353 - 374).

Reviewer 4 Report

Dear Author

　This study shows that HAL is a safe rehabilitation tool after tendon lengthening in CP. On the other hand, the results should be interpreted with caution because of the variation in severity of illness in the subjects. The description of the results also needs to be reconsidered.

 

Major Comments

 

1.         With regard to Table 1, there is a large variation in HAL training days. Has this affected the results? Please provide clear reasons in the manuscript.

 

2.         In Table 3, results are substantially lacking for 10MWT, 6MWT and PCI. It is therefore difficult to suggest whether HAL in particular affects endurance. Please revisit the discussion of endurance in the manuscript.

 

3.         Table 2 is not clear to the reader.

What do Knee (n=2) and Ankle (n=4) in Patient no 1 indicate?

Overall, Table 2 needs improvement.

 

4.         L162-163, 「In patients 2, 4, and 6, the COPM was difficult to administer owing to the patients’ intellectual disabilities.」

L216-P10：L217, 「In patient 4, it was difficult to measure the maximum isometric knee extension torque because of intellectual disability.」

→Shouldn't patient 2, 6 be excluded from the measurement of muscle strength because of his intellectual disability?

 Mainor Comments

1.         L140-141: The study participants were six patients with CP (mean age, 16.0 [range, 11–24] years; 140 four male participants) who were scheduled to undergo tendon lengthening in their lower 141 extremities (Table 1).

→This description should be included in 2.1. Patients.

 

2.         L157-159：Gait training using HAL lower limb type S size was initiated after the postoperative fixation period (28 [14–42] days on average) and after the surgeon determined that standing training was possible.

→Deleted as also stated in HAL intervention.

 

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

I appreciate your efforts to follow my suggestions. 

Even so, a few adjustments still could be made.

1. The outcomes should be briefly descript in the methods section.

2. The resolution of figure 2 needs to be improved

3. Table 2 is long and difficult to follow. I suggest presenting the measures that represent the evaluated group, instead of describing the result of each participant. The same for Table 3, which is very wide and does not allow you to see the last columns.

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

Dear. Author

I thank you for revising the manuscript according to my comments. I have no comments to make on the manuscript as it is very well written.

Author Response

 

Response to Reviewer 4 Comments

Response

We thank the Reviewer for their thoughtful comments, which have helped us significantly our manuscript. We are grateful for the time and energy you expended on our behalf. Thank you very much for providing important insights.