Optimising Scar Management Intervention in the Case of a Head-and-Neck Burn for a Patient with a Learning Disability

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript describes the use of computer-aided design for the development of serial static orthoses to address the needs of a burn survivor with learning disabilities. Although this approach does provide a novel solution for a unique challenge the authors do not provide any data to support the efficacy of this treatment intervention, nor do they make the design files freely available. If the authors are willing to make the design files available this would constitute a value contribution to the rehabilitation community and would be consistent with the culture and traditional practice in the arena of 3D-printing rehabilitation. In addition, there are a number of inaccuracies in the literature review provided.

Line 93: A 3D-printed orthosis has previously been presented by Almendinger and Rosenstiel (Almendinger J, Rosenstiel J. 755 3D Printed Mouth Stretcher. Journal of Burn Care & Research. 2023;44(Supplement_2):S160-S.)

Line 96: The microstomia literature, at a minimum, includes vertical and horizontal mouth opening measures, but more fulsome evaluation would include a functional evaluation with the MIDA (Couture MA, Calva V, de Oliveira A, LaSalle L, Forget N, Nedelec B. Development and clinimetric evaluation of the mouth impairment and disability assessment (MIDA). Burns. 2018;44(4):980-94.). Provision of data to support that the patient’s mouth opening measures should have been provided in addition to data confirming that the patient adhered to the prescribed wearing schedule.

Line 155: A series of static devices designed to increase tissue length is referred to as a serial static orthosis not a dynamic orthosis (McKee, P., & Morgan, L. (1998) Chapter 1: Objectives, design, and terminology (pp. 1-18). In Orthotics in rehabilitation: Splinting the hand and body. Philadelphia, PA: F.A. Davis.). This design approach is very commonly employed in burn survivor rehabilitation therefore it is important to utilize accurate terminology to ensure consistency across the literature.

The results section does not provide any outcome data, either quantitative or qualitative, to justify why this design is superior to the dozens of designs that have already been published. 

Author Response

Thank you for your comments, and recommended references. We have reviewed these and revised our text accordingly. With regards to the MIDA and outcomes - due to the patients learning difficulties, we were unable to collect any reliable quantitative data on outcomes, other than patient qualitatively reporting she was able to return to her usual diet and activities. Our main hope with this paper is to demonstrate a novel device, but requires further use and validation in the future.

We will also make our STL files available with this paper.

Reviewer 2 Report

Comments and Suggestions for Authors

The patient photographs appear to show only minimal peri-oral scarring, calling into question whether there was any need for such an intervention to begin with as microstomia tends to occur in those with stiff burn scars (such as those shown on the chest). Nevertheless, the review of post-burn microstomia is well done and conceptually the custom 3D printed devices shaped as a lolly was a very creative solution that is worth sharing.

Author Response

Thank you for your response and comments. Our main hope with this paper is to demonstrate a novel device, which naturally requires further use and validation in the future.

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript concerns a case study report concerning the development a bespoke mouth opening device utilising computer-aided design (CAD) replicating an ice-lolly, enhancing the patient’s understanding along with encouraging independence. This case report discusses the individualised care and rehabilitation provided to a burns patient with a learning disability. To improve the present paper, the following suggestions are provided for the authors' consideration:

 

General remarks:

·        The text written under “Results” is in fact a description of the treatment and should be part of the method section.

·        The manuscript appears to be deficient in functional assessments aimed at comparing pre- and post-intervention conditions. Were evaluations such as the Maximal Mouth Opening (MMO) or the Mouth Opening Index (MOI) conducted prior to and following the intervention? In the absence of pre- and post-intervention measurements, it is advisable to juxtapose the final outcomes with those observed in individuals without medical conditions.

·        The manuscript lacks assessments of quality of life (QoL). The Oral Health Impact Profile (OHIP) is a recommended tool for such evaluations. Should the OHIP or a similar instrument not have been utilized, the absence of a QoL assessment ought to be acknowledged as a limitation of the study.

·        The organization of the manuscript does not conform to the generally accepted guidelines for case study reports. The literature review should be integrated within the introduction section. Following the introduction, the case presentation should be presented, which must include:

o   Patient Information: 

o   Clinical Findings 

o   Assessment of microstomia severity.

o   Therapeutic Intervention: Describe the orthopedic device, including its design, application process, and any adjustments made during the treatment.

o   Follow-Up and Outcomes: Document the patient’s progress, any complications, and the outcomes of using the device.

 

Literature review:

·        A search string is missing.

·        While it is true that there is no universally recognized protocol for administering rehabilitation therapy to patients with burns affecting the head, face, and neck, two comprehensively conducted surveys on current rehabilitation practices offer valuable insights into the broadly accepted treatment methodologies.

Serghiou 2004 J Burn Care Rehabil. 2004 Nov-Dec;25(6):514-8

Clayton 2017 J Burn Care Res. 2017 Jan/Feb;38(1):e204-e211

 

L180 “All mouth opening devices utilised in this case were used for a period of 5 minutes, 3-times per day”. Where was this protocol based upon? Was it an existing protocol? Was it specially adapted for the patient? Please clarify.

L207 “It is also accepted that mechanical force and stretch on scars can contribute to the development of pathological scarring”. Can you clarify this statement with regard to the intervention you used? How could the intensity, duration and frequency of the intervention lead to beneficial effects when taking into account this statement?

 

Conclusion

Given that this document is merely a case report on a device employed as a preventive measure, lacking pre- and post-intervention evaluations, the conclusion should stipulate that the efficacy of the device necessitates validation through extensive testing across a larger cohort to facilitate generalizability.

Author Response

Thank you for your comments, and recommended references. We have reviewed these and revised our text accordingly. With regards to the functional assessments and outcomes - due to the patients learning disability, we were unable to collect any reliable quantitative data on outcomes, other than patient qualitatively reporting she was able to return to her usual diet and activities. Our main hope with this paper is to demonstrate a novel device, but naturally requires further use and validation in the future.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Please substitute the term adherence for compliance throughout the manuscript (Mir TH Adherence Versus Compliance. Healthcare Journal of Medicine (2023) 4:2 https://doi.org/10.36518/2689-0216.1513). 

It continues to be surprising that treatment is initiated with out any baseline measures or follow up measures to objectively demonstrate efficacy. 

Reference 44 does not exist in the manuscript. It appears that it should be reference 6. Please correct. 

I believe the STL files should be in an appendix and referred to in the therapeutic intervention description of the manuscript rather than the conclusions. 

 

Author Response

Thank you for your comments. We have reviewed these and updated our manuscript accordingly.

Reviewer 3 Report

Comments and Suggestions for Authors

Some typographic errors should be corrected.

Introduction:

1. "was a key element" should probably be "were key elements" to maintain agreement with both "social and psychological factors."
2. "what would late become known as" should be "what would later become known as."

Literature review

1. "Pubmed" should be "PubMed".
2. "respondant" should be "respondent."
3. "Serghio et al’s" should be "Serghiou et al.'s"
4. "it’s use has" should be "its use has"

Therapeutic Intervention

1. "52mm, 58mm and 63.5mm wide," should be "52 mm, 58 mm and 63.5 mm wide,"

 

Discussion

• "scaring" should be "scarring" in "hypertrophic and keloid scaring."
• Ensure consistent terminology, such as the use of "three-dimensional printing" and "3D printing," and "computer-aided design" and "CAD." It's best to choose one form and stick with it throughout the document.

Author Response

Thank you for your comments. We have reviewed these and updated our manuscript accordingly.