Applied COP-Based MMSE Method and Modular Interactive Tiles on Postural Stability Enhance in Patients with Chronic Stroke: A Pilot Study

Round 1

Reviewer 1 Report

• Abstract Lines 32-34“the training program positively affected the CI of MMSE values as the BBS values of the patients, indicating their improved balance and ability to avoid falls.” Can the authors explain this especially where they report “MMSE values as the BBS values of the patients”?
• Page 4, lines 4-5 “Is a pilot study, subject to the limitations of the IRB requirements for patient safety and research 4 funding, research samples are not easy to obtain,” Proper sentence restructuring is needed.
• Page 4 – Lines 8-12: “So for future analysis, research scholars may recruit stroke patients who take part in the original 8 rehabilitation protocol without adopting the MITs in order to detect the differences, if any, between 9 the training programs with and without the MITs. For randomized controlled studies, control 10 subjects with the same conditions can be recruited to make sure that the participants who participate 11 in the 12-week exercise program achieve a better ability to control their postural stability.” This would be better served in the discussion section and not in the methods section.
• Page 4, lines 13-14: “In addition, according to the Berg Balance Scale （BBS）, we excluded patients at a high risk of 13 falling, neither of the subjects is at increased risk for falls.” Grammatical corrections are needed.
• Page 4, lines 14-19 “So the results of this study could not be generalized to the patients for poorer balance. For future research, we may recruit patients who continue the original rehabilitation without adopting the MITs, to detect the difference with and without MIT training programs. In addition, considering the ceiling effect in BBS, we suggest adding more challenge scales （g. the Four Step Square Test） for future studies, so as to ensure the validity and reliability of the results.” This would again be better served in the discussion section and not in the methods section.
• The limitations of the study some of which were included in the methods section should be described as “limitations” in the discussion section. This is a well performed study overall, but with a small sample size that should be acknowledged by the authors as a major limitation.  

Author Response

 "Please see the attachment."

Author Response File: Author Response.pdf

Reviewer 2 Report

 

Chen et al. have presented benefits of the pilot study containing virtual reality (VR) feedback system with modular interactive tiles (MITs) training in the rehabilitation of stroke patients. Although the manuscript is well-prepared and highly impactful, I have few concerns that need to be addressed by authors:

1. What is the status of other diseases/conditions in the patients? Risk of falls is attributed to many conditions, for instance, alzheimer's, heart failure, eye disorders, medications, so on and so forth. (exclusion criteria mentioned diabetes and other neuromuscular deficits only)
2. Family history of falls or personal history of falls or osteoporosis in these patients before stroke? It might significantly alter the outcomes.
3. Authors obtained significant results in postural ability with 12-week training program performed at hospital or rehabilitation center. As stoke is chronic debilitating disease, what if the significant improvement obtained in 12-weeks is transient? Do these patients need lifelong training to get the required benefit out of it? My only concern is acute effect of these trainings rather than chronic sustained effects. 
4. If it is possible, could the effects of the trainings be studied after 24-weeks? Or after 12-weeks, could the significant improvement be sustained at home by performing routine follow-up physical training, physiotherapy, etc.?
5. The data in the manuscript indicate that postural stability is improved in the subject with stroke, however, the actual fall risk has not been calculated pre- and post-training regimen. Such risk using FRAS or mRS or any other well-known scale/scoring must be evaluated.

 

Author Response

"Please see the attachment."

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

  Authors have explained all my queries extremely well. After carefully revisiting the revised manuscript and the comments, I am happy that the manuscript is improved substantially. Congrats to authors!