The Experience of Physical Recovery and Physical Rehabilitation Following Hospital Discharge for Intensive Care Survivors—A Qualitative Systematic Review
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
The MS deals with health-related quality of life in critical illness survivors. This represent an important issue in the context of physical recovery and physical rehabilitation following hospital discharge.
The study represents the qualitative systematic review (following both the Joanna Briggs Institute methodology and PRISMA), in which seven studies were identified to be used to final analysis. The studies were based on the data from the UK, US, Denmark, Canada and Australia.
Please clarify few issues within the MS:
In the introduction section are not mentioned the evidence based expected benefits of rehabilitation (exercise programmes) in ICU survivors after discharge from hospital – clearly define why this topic is important. Also these information are missing: how the exercise programme after discharge are actually organized in other groups of patient and how provably effective these programmes are. This would support the introduction section.
Concerning the methodology section number of participants included in the final analysis is missing. Also the information how the synthesized findings were realized (On what number of participants these are made of?) This information would further support the findings.
I even miss studies concerning the adherence for home-based rehabilitation programmes (which also represent serious issue when is emphasis put on exercise programmes).
What is meant by structured exercise programmes?
“Rehabilitation interventions have not been evaluated in a qualitative manner” – what exact type of rehabilitation intervention is meant by this?
In conclusion is stated that: “The findings indicate that ICU survivors struggle to access services following discharge home, leaving them fighting for support, feeling abandoned and wanting to know.” But these findings are limited to specific population of unknown size.
Author Response
Thank you for your comments and suggestion. Please find the responses in italics below.
Please clarify few issues within the MS:
In the introduction section are not mentioned the evidence based expected benefits of rehabilitation (exercise programmes) in ICU survivors after discharge from hospital – clearly define why this topic is important. Also these information are missing: how the exercise programme after discharge are actually organized in other groups of patient and how provably effective these programmes are. This would support the introduction section.
Answer: A Cochrane review of rehabilitation following intensive care unit discharge was carried out in 2015 by Connolly et al. This review identified that studies in this area were frequently small and were lacking in methodological rigour, leaving the authors unable to complete a meta-analysis. They identified the need for further research to determine the effects of an exercise-based intervention. Despite this, its is widely known that Post ICU Syndrome (PICS) is found in a significant number of ICU survivors who demonstrate ongoing physical effects, and therefore the need for rehabilitation is clear. Currently there is no clear guidance or evidence for the most beneficial form, of rehabilitation following discharge home after intensive care. This has been added on page 2 lines 80-84
Concerning the methodology section number of participants included in the final analysis is missing. Also the information how the synthesized findings were realized (On what number of participants these are made of?) This information would further support the findings.
Answer: This has been added in page 7 lines 287-pg 8 line 291
I even miss studies concerning the adherence for home-based rehabilitation programmes (which also represent serious issue when is emphasis put on exercise programmes).
Answer: we agreed that adherence is an issue, although at present there is no conclusive evidence for the use of home-based programmes or supervised programmes so I think adherence data will be something to develop in the future. We have not added information to the review regarding adherence as this would require significant space for discussion which we feel would make the review too long.
What is meant by structured exercise programmes?
Answer: These are programmes where the participant follows a prescribed format of exercises. The reason for using this terms is that this covers both structured, unstructured, aerobic and strengthening programmes.
“Rehabilitation interventions have not been evaluated in a qualitative manner” – what exact type of rehabilitation intervention is meant by this?
Answer: rehabilitation can cover structured exercises (as explained above) and also general physical activity or advice on functional activity. There have been many rehabilitation programmes but very little qualitative evaluation.
In conclusion is stated that: “The findings indicate that ICU survivors struggle to access services following discharge home, leaving them fighting for support, feeling abandoned and wanting to know.” But these findings are limited to specific population of unknown size.
Answer: in the UK, the population if ICU survivors is known. The Intensive Care National Audit and Research Council (ICNARC) published survival rates following discharge on an annual basis and the figure is included within the introduction. This fluctuates as would be expected but is consistently over 100,000. It may be more difficult to determine the population size in some other countries.
Reviewer 2 Report
Comments and Suggestions for Authors
This was an easy to read, well-conducted review of the literature exploring the patient experience of post-ICU rehabilitation. I have minor comments only - mostly typographical:
* line 46 should have 'and' rather than the comma
* line131/132 the authors have both PICO and PICo.
* line 331 has an unnecessary full stop in the middle of the sentence
* In the conclusion section, despite consistency throughout the manuscript to refer to the intensive care unit or ICU, the authors switch to ITU
* More general points:
- I was surprised that the authors didn't include 'ITU' in their search terms. A brief comment on this would be helpful
- It would be useful to know how many additional papers might have been identified if the search had not been limited to publications in English
- there are two sub-themes that I identified from the points made by the authors that would be good to explore more in the manuscript, in the wider context of the patient experience of intensive care:
-- loss of control/regaining control: supported around line 317 by the patient saying "I'm not allowed to... they won't let me..." This is an extension of the loss of control that many patients express during their ICU stay and may be related to an ongoing directive nature of recovery. The regaining of control is highlighted in several places (eg line 357 "the importance of independence"; line 360 "happiness is doing things yourself"; line 372 "when I can walk again, it will be different")
-- similarly uncertainty is something that many patients (and healthcare professionals) talk about in relation to ICU and the liminal balance around survival. It is interesting that this overflows into the recovery period as well
Overall though, very good reporting and sensible analysis.
Author Response
Thank you for your review and your kind comments and suggestions. Please find our responses in italics below and the changes highlighted in the revised manuscript.
This was an easy to read, well-conducted review of the literature exploring the patient experience of post-ICU rehabilitation.
I have minor comments only - mostly typographical:
* line 46 should have 'and' rather than the comma - added
* line131/132 the authors have both PICO and PICo. – adjusted now in lines 140 & 142
* line 331 has an unnecessary full stop in the middle of the sentence – this has been corrected
* In the conclusion section, despite consistency throughout the manuscript to refer to the intensive care unit or ICU, the authors switch to ITU – this has been corrected and the term ICU had been used throughout, including the Figure 2 label
More general points:
- I was surprised that the authors didn't include 'ITU' in their search terms. A brief comment on this would be helpful –
although ITU is still used commonly in clinical practice the term “Intensive Therapy unit” is not used in the literature within the field and therefore it was felt that the phrases included would capture all relevant material. The authors also referred to existing search terms in other reviews to ensure phrases in this review search matched those commonly used.
- It would be useful to know how many additional papers might have been identified if the search had not been limited to publications in English – unfortunately we did not collect that data.
- there are two sub-themes that I identified from the points made by the authors that would be good to explore more in the manuscript, in the wider context of the patient experience of intensive care:
-- loss of control/regaining control: supported around line 317 by the patient saying "I'm not allowed to... they won't let me..." This is an extension of the loss of control that many patients express during their ICU stay and may be related to an ongoing directive nature of recovery. The regaining of control is highlighted in several places (eg line 357 "the importance of independence"; line 360 "happiness is doing things yourself"; line 372 "when I can walk again, it will be different")
– this is a very interesting point. The authors interpretation of the data focused on independence but this goes hand in hand with regaining control of function and activities of daily living. We have added this into the discussion – pg13 line 580-581
Reviewer 3 Report
Comments and Suggestions for Authors
Thank you for the opportunity to review the paper entitled, "The experience of physical recovery and physical rehabilitation following hospital discharge for intensive care survivors-a qualitative systematic review." While the paper was well written overall and would be of interest to clinicians I think there are some inconsistencies that need to be addressed in order to better understand the study design that was used.
Title: should include "Scoping Review," as per the PRISMA extension for Scoping Reviews checklist and to be clear what type of method was used.
Abstract-you should be using the PRISMA extension for Scoping Review (PRISMA-ScR) by Tricco A, et al. Annals of Internal Medicine. 2018. However, after to reading a bit more I think you meant to say, "Preferred Reporting Items for Systematic Reviews and Meta-analyses," not Scoping review. Please correct/clarify. There is a difference between a qualitative systematic review versus a scoping review so be clear which one you have done and the correct reporting guidelines.
In-text citation is not consistent throughout-see line 38 versus line 56 vs. line 69-review journal requirements for proper in-text citation and be consistent
Introduction:
Line 47- It is unclear what "Intervention," is being referred to here
Line 71- You say "The updated survey published in 2021..," like we should know what survey you are referring to. Can you please provide a bit more detail in regards to the study you are referencing. Maybe you can add a bit of the detail from the next sentence.
Line 98-101-This sentence is too long. I would break it up as it seems like you need to cite the portion that is results from the prior study you mentioned.
I would end your introduction with the aim/objective of the current review.
Methods:
Line 128-In the abstract you say your are using PRISMA for reporting guidelines, but here you say ENTREQ guidelines. Please be consistent.
Lines 119-123- the research objectives listed here do not align with the aim stated at beginning of the discussion section or that stated in the abstract. I would just stick to the aims stated in abstract/discussion as I don't believe your results address all the objectives listed. Please revise.
Results:
Long but well written. I like all the quotes. I know qualitative results sections are often longer, but I would try to trim it down a little bit as you may begin to lose the reader.
Discussion/Conclusion:
Both well written. Nice work.
Author Response
Thank you for your helpful comments and suggestions .Please find the answers in italics below and changes highlighted in the revised manuscript.
Thank you for the opportunity to review the paper entitled, "The experience of physical recovery and physical rehabilitation following hospital discharge for intensive care survivors-a qualitative systematic review." While the paper was well written overall and would be of interest to clinicians I think there are some inconsistencies that need to be addressed in order to better understand the study design that was used.
Title: should include "Scoping Review," as per the PRISMA extension for Scoping Reviews checklist and to be clear what type of method was used. –
Answer – we did conduct a systematic review of the literature. Your point below is correct in saying that we mis-referenced the PRISMA stating scxoping review when it should have read as systemtic review. We have corrected this.
Abstract-you should be using the PRISMA extension for Scoping Review (PRISMA-ScR) by Tricco A, et al. Annals of Internal Medicine. 2018. However, after to reading a bit more I think you meant to say, "Preferred Reporting Items for Systematic Reviews and Meta-analyses," not Scoping review. Please correct/clarify. There is a difference between a qualitative systematic review versus a scoping review so be clear which one you have done and the correct reporting guidelines.
Answer – thanks you for your comment. You are correct. We completed a Systematic review as per the JBI methodology and therefore it should have been "Preferred Reporting Items for Systematic Reviews and Meta-analyses,". We have corrected this – pg 1, line 15/16
In-text citation is not consistent throughout-see line 38 versus line 56 vs. line 69-review journal requirements for proper in-text citation and be consistent
Answer – thank you. This has been corrected throughout.
Introduction:
Line 47- It is unclear what "Intervention," is being referred to here
Answer -Reworded to read “ the study also demonstrated functional deficits….. pg 2, line 50
Line 71- You say "The updated survey published in 2021..," like we should know what survey you are referring to. Can you please provide a bit more detail in regards to the study you are referencing. Maybe you can add a bit of the detail from the next sentence.
Answer – we have .broken the paragraph differently to make the discussion of the two surveys by Connolly et al (2014 and 2021) more clear. Wording change in pg 2, line 73
Line 98-101-This sentence is too long. I would break it up as it seems like you need to cite the portion that is results from the prior study you mentioned.
Answer – the sentence has been revised and split into two. As a result of other changes to the manuscript the changes are now at Pg 3, lines 106-110
I would end your introduction with the aim/objective of the current review. The review aim has been taken out of the beginning of the materials and methods and added to the end of the introduction which avoids repetition. Pg 3, line 124-126
Methods:
Line 128-In the abstract you say your are using PRISMA for reporting guidelines, but here you say ENTREQ guidelines. Please be consistent.
Answer – we have changed this to the PRISMA guidelines. Although the review does answer both PRISMA and ENTEREQ requirements, we can see that it helps to limit this to improve consistency. Pg 3, line 138
Lines 119-123- the research objectives listed here do not align with the aim stated at beginning of the discussion section or that stated in the abstract. I would just stick to the aims stated in abstract/discussion as I don't believe your results address all the objectives listed. Please revise.
Answer – now pg3, lines 124-18. The study objectives were identified within the protocol and therefore we feel these have to remain in the final review. We have included discussion of the objectives and therefore feel that leaving them out of the materials/methods would perhaps be disjointed for the reader. We have made the aim of the study clearer at the end of the introduction as suggested. We have also made it clearer in line 124, that the objectives were identified at the protocol stage. The objectives are referred to in the discussion in pg 13, line 536; pg 13, line 579 and pg 14, line 601. We hope this provides better evidence of the continuity.
Results:
Long but well written. I like all the quotes. I know qualitative results sections are often longer, but I would try to trim it down a little bit as you may begin to lose the reader.
Discussion/Conclusion:
Both well written. Nice work.
Answer - Thank you for your comments and suggested modifications.
Reviewer 4 Report
Comments and Suggestions for Authors
Dear authors,
Many thanks for submitting your manuscript to the journal. I have made some comments on your work that are depicted in the attached file.
Best regards
Comments for author File: 
Comments.pdf
Author Response
Thank you for your helpful comments and suggestions. Please see our responses below in italics after your comments. The changes are highlighted in the revised manuscript.
Abstract: The conclusions provided are more suggestive of the study’s results than the conclusions. Please correct.
Answer – this has been reworded to follow the conclusion. This can be seen below and on pg 1, lines 25-32
Survivors struggle to access healthcare professionals and services following discharge home which influences the momentum of physical recovery. Supervised exercise programmes had a positive impact on perception of recovery and motivation. However ‘simple’ structured exercise provision will not address the range of challenges experienced by ICU survivors. Whilst some factors influencing physical recovery are similar to other groups, there are unique issues experienced by those returning home after critical illness. It is unlcear from existing research what services or interventions survivors feel would meet their needs and assist their physical recovery.
You should give the definitions of the terms physical recovery and physical rehabilitation. Are these terms the same for the study purposes, the search strategy and the study selection process. Please elucidate.
Answer – the use of these terms is the same throughout the review, search and study selection. The clarification exists to separate the recovery of physical function from the psychological issues and rehabilitation which are experienced by intensive care survivors. Other studies have included both physical and psychological issues.
Definition: Physical recovery refers to the progression and return of physical function, and the ability to complete activities of daily living relevant to the individual’s previous activity levels. This does not include psychological recovery.
: Rehabilitation is the process of helping someone recover from injury or illness and regain their strength and mobility.
In this review we focused on physical rehabilitation and did not consider psychological rehabilitation which has been the focus of other studies. These definitions have been added to the methods in pg 3 line 143-pg 4 line 149
Page 7, line 283 Please write synthesised finding 1 instead of synthesized finding:. In addition, organise in-text the categories of the synthesized finding 1 with the order in which they have been illustrated in Figure 2. The second comment concerns also the the subsections “Synthesized finding 2” and ”synthesized finding 3”.
Answer – This has been adjusted and Figure 2 has been altered to reflect the order of discussion in the results.
Figure 2 – please define the abbreviate ITU
Answer – as suggested by another reviewer, we have removed the references to ITU to improve consistency and have used ICU throughout the review. We hope this addresses this issue and improves consistency.
Discussion: please give a comprehensive synopsis of the main findings of the present study in the first paragraph of the section.
Answser – this has been included as requested and can be seen on page 12, lines 512-523
Your discussion has been structured in the strength of the objectives of the study. For each objective I would like to see a substructure based on the synthesized findings of your study
Answer – thank you for raising this point. We had originally structured the discussion as you have suggested. However, but it was felt that the discussion became repetitive of the results, and excessively lengthy. The submitted discussion, as you rightly point out, aims to provide an answer to the study objectives, is still based upon the findings, but also draws in other wider evidence. I hope this justifies the structure. We would like to keep it as it is presented in the revised document to prevent it becoming repetitive or too lengthy.
Page 14, line 599: give the full form before providing the first abbreviated form ITU. Specifically Intensive therapy unit.
Answer – as explained we have now used ICU consistently through the review which we hope improves clarity.
Conclusion: please give a more detailed and specific proposal for further research.
Answer – this has been clarified in more detail. Pg15, lines 662-666
