Effectiveness of Digital Physiotherapy Practice Compared to Usual Care in Long COVID Patients: A Systematic Review

Round 1

Reviewer 1 Report

Thank you for the opportunity to review the manuscript “Effectiveness of Digital Physiotherapy Practice Compared to Usual Care in Long Covid Patients. A Systematic Review”.

This systematic review included 6 RCTs of moderate to poor methodological quality.

The theoretical assumptions, presented in the introduction, are relevant to explain the study rational.

The Materials and Methods are very well founded. The results present the necessary information for an analysis of each of the included studies (general characterization table). The Subgroup Analysis by Intervention tables also reveal relevant insight that explores different views of the authors and may be of great interest to the reader.

As there is no comment that I consider obligatory, in order to correct any error or to improve any part of the article, I only leave some questions to the authors for reflection and, eventually, to add to the discussion and limitations of the study:

Page 13

Lines 82-83

You are correct! However, you could take the opportunity to discuss the interest of the scientific studies - to serve the health professional (and other professionals) or the people/society/patients/etc.?

Is it more important to understand which modality is more effective or whether the combination of those evidence-based modalities is better for the person/patient? Just a thought...

Lines 101-104

This idea deserved further reflection by the authors because of its relevance and because it could add knowledge and stimulate a discussion within the scientific and clinical community. What do the authors think about this issue?

Lines 112-114

These studies (2016 and 2020) were before Covid-19 pandemic. Is it true now? Please considere this as a "authors backstage discussion" and review the sentence.

Lines 121-126

I'm not sure if it should be here in the "Limitations" that this issue should arise, but:

- what do the authors think about a subject that is currently much questioned and that relates to the evaluation of results and the use of reliable and valid instruments to be used remotely. How, in each of these 6 studies, is the initial, final and follow-up evaluation process described? It could enrich this review if this issue came up in the discussion or even in the limitations.

Comments for author File: Comments.pdf

Author Response

The authors want to thank your thoughtful and constructive comments. All the suggestions were considered and were included into the revised manuscript. Our manuscript has been substantially improved because of the modifications. An itemized point-by-point response to the reviewer’ comments is presented below in attached document

Author Response File: Author Response.pdf

Reviewer 2 Report

The authors state that they conducted a systematic literature review aimed at evaluating the effectiveness of digital physiotherapy practice compared to usual care in patients with Long Covid.

It is noted that the title is quite broad and does not correlate precisely with the PICO question posed. Additionally, the abstract is not structured according to the journal's guidelines.

The extensive use of databases in the review is noteworthy; however, it is suggested to include the search algorithms used for each database. Similarly, in the PRISMA diagram, the reasons for excluding the 353 articles should be indicated.

Regarding the PICO question, it is important to ensure how patients with specific ICD-10 codes were selectively included. Furthermore, the outcomes are not defined according to the guidelines outlined by the Cochrane review.

Table 1 in the Results section is not easily comprehensible. As for Table 2, it merely repeats what is stated in each article without providing a critical analysis of the results.

In the conclusions, it is asserted that remote interventions are equally effective as in-person interventions. However, the evidence presented is inconclusive to support this claim.

The discussion should be improved by providing a more thorough analysis of the results and addressing the study's limitations in greater detail.

Author Response

The authors want to thank your thoughtful and constructive comments. All the suggestions were considered and were included into the revised manuscript. Our manuscript has been substantially improved because of the modifications. An itemized point-by-point response to the reviewer’ comments is presented below in attached document

Author Response File: Author Response.docx

Reviewer 3 Report

In line 147, you said "The review was conducted according to the registered protocol: CRD42022379004" Where was it registered?

No article looked at social differences as a determinant?

Do you think that the use of mobile applications could also help in adherence to digital physiotherapy?

Author Response

The authors want to thank your thoughtful and constructive comments. All the suggestions were considered and were included into the revised manuscript. Our manuscript has been substantially improved because of the modifications. An itemized point-by-point response to the reviewer’ comments is presented below in attached document

Author Response File: Author Response.docx

Reviewer 4 Report

The authors carried out a review regarding digital physiotherapy practice in Long COVID patients in twelve databases until December 2022. The paper is very complete and well writen, with some minor errors found and listed in sequence.

"Effectiveness of Digital Physiotherapy Practice Compared to Usual Care in Long Covid Patients. A Systematic Review" -> "Effectiveness of Digital Physiotherapy Practice Compared to Usual Care in Long Covid Patients: A Systematic Review" (please avoid using "." in the title of the paper)

General comments and minor errors found are listed as follows.

" groups was found." -> " groups were found."

"Digital physiotherapy practice 1; Telerehabilitation 2; Telemedicine 3; Long COVID 4; Persistent COVID syndrome 5" -> "Digital physiotherapy practice; Telerehabilitation; Telemedicine; Long COVID; Persistent COVID syndrome"

"and mood among others" -> "and mood, among others"

"COVID  has" -> "COVID has"

"recommended a multidisciplinary rehabilitation approach with strong recommendation" -> please rewrite

"practice, is defined" -> "practice is defined"

"Appendix A. Figure A1" -> "Appendix A, Figure A1"

"Appendix A. Figure A2" -> "Appendix A, Figure A2"

" from 2019" -> please specify the range (from 2019 to ?) (this information is only available in the abstract)

"English, or Spanish" -> "English or Spanish,"

"The intervention must have been an intervention " -> please rewrite

"Comparison:  Digital" -> "Comparison: Digital"

"Digital physiotherapy practice compared with usual care and educational care for Long COVID symptoms." -> this sentence seems loose or repeated in the text

"Secondary outcomes: Secondary outcomes may" -> please rewrite

"trials [RCT], were" -> "trials [RCT] were"

"Risk of Bias." -> "Risk of Bias"

"in a  Flowchart," -> "in a Flowchart,"

"are presented in Table 1." -> "is presented in Table 1."

"et al" -> "et al."

"et al" -> "et al."

"et al" -> "et al."

"et al" -> "et al."

"et al" -> "et al."

"et al" -> "et al."

please improve quality of Figure 2 (text is blurred)

please improve quality of Figure 3 (text is blurred)

"of included trials." -> "of included trials"

"estimated  at" -> "estimated at"

"pressure  and" -> "pressure and"

"pressure  during" -> "pressure during"

" found  between" -> " found between"

"were 20.12  seconds  post-treatment " -> "were 20.12 seconds post-treatment "

" seconds  at" -> " seconds at"

"include four" -> "included four"

please use "." instead of "," for separating decimals in table 3

" capacity was found " -> " capacity were found "

"3 of them [35,36,38] " -> "3 of them [35,36,38]. "

"From a cognitive and psychological status [35,37], were numerically better in the intervention group than the control, although differences were not statistically significant." -> please rewrite

" in Table 5." -> " in table 5."

" et al " -> " et al. "

" et al " -> " et al. "

" et al " -> " et al. "

" et al " -> " et al. "

" et al " -> " et al. "

" et al " -> " et al. "

"(Quality of Live) (P" -> ?

"(++" -> ?

section 3.3 is not necessary in the paper. please remove intervention

" terms, have" -> " terms have"

" once again the" -> " once again, the"

"[51] the only" -> "[51], the only"

"Is an effective" -> "It is an effective"

Author Response

The authors want to thank your thoughtful and constructive comments. All the suggestions were considered and were included into the revised manuscript. Our manuscript has been substantially improved because of the modifications. An itemized point-by-point response to the reviewer’ comments is presented below in attached document

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

The authors have provided a revised version of the article that, in my initial evaluation, I had considered unsuitable for publication. I appreciate the efforts made by the authors to address some of the concerns raised, however, there are still notable deficiencies in the text that need to be addressed.

Firstly, it is essential to clearly define the concept of "Long COVID" for the purpose of this review. As recognized by the World Health Organization (WHO), "Long COVID" encompasses a broad spectrum of symptoms and manifestations, including up to 300 different reported symptoms. Therefore, it is crucial to provide a precise definition and criteria to guide the review process and ensure consistency in the evaluation of relevant studies.

Additionally, further clarification is needed regarding the peer review process and the exclusion of 347 articles. It would be beneficial to clearly state the criteria and reasons for excluding these articles in the PRISMA flowchart. This transparency is essential for readers to understand the selection process and evaluate the reliability of the study.

Moreover, the approach to assessing heterogeneity should be elaborated upon. While the authors mention evaluating heterogeneity, they do not provide details on the methods or statistical tests used. It is important to present the relevant statistical analysis, such as forest plots, if heterogeneity is assessed. This information would enhance the transparency and validity of the review findings.

In Table 4, there appears to be a discrepancy between the stated objective of presenting outcomes and the actual presentation of bias assessment results. It is recommended to clearly align the content of the table with the stated objective to avoid confusion for readers.

Furthermore, in Table 5, the assignment of "++" to each article is not described in the Methods section. It would be beneficial to include an explanation of how the ratings were assigned to ensure transparency and reproducibility.

In the conclusion section, while the authors state that digital intervention is effective, the statement is not adequately supported by the reviewed studies or the analysis conducted. It is crucial to provide a balanced and evidence-based conclusion that accurately reflects the findings of the review.

Lastly, the manuscript would greatly benefit from a thorough language revision by a native English speaker with expertise in health-related topics. This would help to improve the overall clarity and readability of the text.

Considering the aforementioned concerns, I would recommend that the authors consider presenting their work not as a systematic review but as a narrative review. This approach would allow for a more comprehensive discussion of the topic while addressing the limitations identified during the review process.

See lines 181, 156, 142, 118, 56

Author Response

Please see the attachment.

Response to Reviewers (Healthcare-2427177)

Dear Reviewer,

The authors want to thank your thoughtful and constructive comments. All the suggestions were considered and were included into the revised manuscript. Our manuscript has been substantially improved because of the modifications. An itemized point-by-point response to the reviewer’ comments is presented below.

RV2: Reviewer

AA: Authors

Author Response File: Author Response.docx