The Relationship between Clinical Tests, Ultrasound Findings and Selected Field-Based Wheelchair Skills Tests in a Cohort of Quadriplegic Wheelchair Rugby Athletes: A Pilot Study

Round 1

Reviewer 1 Report

1. The topic is a highly worthy one. The subject matter will undoubtedly grow and develop tremendously over the decades to come.
2. The authors have done a lot of work and their findings will represent important contributions to the literature.
3. The volume of material is overwhelming. This seems like a PhD thesis boiled down into a single paper. Perhaps it would be more palatable to readers as a few more focused papers.
4. There are sections (e.g. page 2, column 1) where the traditional organization (Introduction à Methods à Results à Discussion) (at least for the journals with which I am more familiar) is not used.
5. There is some unnecessary repetition (e.g. ADA details, IRB approval).
6. The authors make much of the fact that they studied surfaces in 6 different countries. Although this is laudable, it would be wrong to infer that the analysis was comprehensive with respect to every conceivable surface variation in the built and natural environment. For instance, such obstacles as door thresholds (that create difficulties distinct from level changes) and cross-slopes are not mentioned.
7. The work would be more relatable to people working in the rehabilitation world with a few brief mentions of neighbouring topics that are relevant to the current work, specifically:
   1. The “environmental factors” impact on Activities and Participation of the WHO ICF.
   2. The alternative/complementary solution (to accessible routing) of improved wheelchair design (e.g. shock absorption, tire design).
   3. The alternative/complementary solution (to accessible routing) of improved training of wheelchair users and their caregivers (e.g. in how to handle soft surfaces or level changes) (e.g. Keeler et al. Disabil Rehabil Assist Technol 2019;14:391-409).
8. Surface variations can influence wheelchair user comfort and passability (as the authors note), but they can also affect user safety (e.g. if the wheelchair stops or slows suddenly, the wheelchair may tip over forward or the user may fall from the wheelchair).
9. Although 4 different wheelchairs were used, from the photographs in Figure 3, they appeared to have a lot in common. Some additional detail on the wheelchairs might be useful (e.g. pneumatic vs solid tires affect perceived vibration, as does the type of seat cushion). No rigid-frame wheelchair was included, it seems.

Author Response

The topic is a highly worthy one. The subject matter will undoubtedly grow and develop tremendously over the decades to come.

The authors have done a lot of work and their findings will represent important contributions to the literature.

Answer: Thank you for your appreciation.

 

The volume of material is overwhelming. This seems like a PhD thesis boiled down into a single paper. Perhaps it would be more palatable to readers as a few more focused papers.

Answer: This is an original article, not boiled down from a thesis or similar. We think that the number of pages and information included in the study is adequately summarized. Further cuts in the manuscript could compromise the reader’s comprehension of the study.

 

There are sections (e.g. page 2, column 1) where the traditional organization (Introduction à Methods à Results à Discussion) (at least for the journals with which I am more familiar) is not used.

Answer: The text respects the traditional organization: Introduction, Materials and Methods, Statistical Analysis, Results, Discussion, Conclusion and it is not organized in columns.

 

There is some unnecessary repetition (e.g. ADA details, IRB approval).

Answer: Please, can you indicate us where are these repetitions (page, line)? We can’t find them into the text.

 

The authors make much of the fact that they studied surfaces in 6 different countries. Although this is laudable, it would be wrong to infer that the analysis was comprehensive with respect to every conceivable surface variation in the built and natural environment. For instance, such obstacles as door thresholds (that create difficulties distinct from level changes) and cross-slopes are not mentioned.

The work would be more relatable to people working in the rehabilitation world with a few brief mentions of neighbouring topics that are relevant to the current work, specifically:

1. The “environmental factors” impact on Activities and Participation of the WHO ICF.
2. The alternative/complementary solution (to accessible routing) of improved wheelchair design (e.g. shock absorption, tire design).
3. The alternative/complementary solution (to accessible routing) of improved training of wheelchair users and their caregivers (e.g. in how to handle soft surfaces or level changes) (e.g. Keeler et al. Disabil Rehabil Assist Technol 2019;14:391-409).

Answer: Please, can you provide us where this sentence is located (page, line)? We can’t find it into the manuscript.

 

Surface variations can influence wheelchair user comfort and passability (as the authors note), but they can also affect user safety (e.g. if the wheelchair stops or slows suddenly, the wheelchair may tip over forward or the user may fall from the wheelchair).

Answer: Please, can you provide us where this sentence is into the text (page, line)? We can’t find it into the manuscript.

 

Although 4 different wheelchairs were used, from the photographs in Figure 3, they appeared to have a lot in common. Some additional detail on the wheelchairs might be useful (e.g. pneumatic vs solid tires affect perceived vibration, as does the type of seat cushion). No rigid-frame wheelchair was included, it seems.

Answer: Figure 3 shows the results of US shoulder evaluation, we do not mention the kind of wheelchair used from the athletes.

Reviewer 2 Report

The article deals with the important topic of the influence of a technical device on the human body. In manual wheelchairs, adverse effects on the skeletal and muscular systems are common. Therefore, one should strive to minimize such pathological interactions.

 

Introduction

The authors narrowly defined the area in which they carry out their research. I propose to provide the reader with a broader description of the available technical means and methods of biomechanics diagnostics of anthropotechnical systems. Below are my suggestions for changes.

 

Line 38-43: The authors describe the merits of field testing which are beyond dispute. It is worth additionally describing the possibility of implementation on specialized research positions. Such stands simulate field conditions and additionally measure various biomechanical parameters. Additionally, you can introduce the reader what parameters are measured during the tests. In my opinion, the wording "skill tests" is too general and incomprehensible to the reader. Below are some examples of bench tests that measure various biomechanical parameters.

[1] (2019). Effects of the performance parameters of a wheelchair on the changes in the position of the centre of gravity of the human body in dynamic condition. PloS one, 14(12), e0226013.

[2] (2021). The symmetric nature of the position distribution of the human body center of gravity during propelling manual wheelchairs with innovative propulsion systems. Symmetry, 13(1), 154.

[3] (2021). The Impact of the Human Body Position Changes During Wheelchair Propelling On Motion Resistance Force. Journal of Biomechanical Engineering.

[4] (2019) Problems of dynamometer construction for wheelchairs and simulation of push motion. In MATEC Web of Conferences (Vol. 254, p. 01006). EDP Sciences.

[5] (2020). Biomechanical Relationships Between Manual Wheelchair Steering and the Position of the Human Body's Center of Gravity. Journal of biomechanical engineering, 142(8).

 

Line 44-46: I partially agree with the authors because the effects of wheelchair use on the skeletal system are poorly studied. However, in general terms, i.e. the impact of a wheelchair on the skeletal-muscular system, there are many studies. I recommend informing the reader about this in the introduction. Below are some examples of research works in this field.

[1] (2020). Impact of a hybrid assisted wheelchair propulsion system on motion kinematics during climbing up a slope. Applied Sciences, 10(3), 1025.

[2] (2020). Evaluation of the Biomechanical Parameters of Human-Wheelchair Systems during Ramp Climbing with the Use of a Manual Wheelchair with Anti-Rollback Devices. Applied Sciences, 10(23), 8757.

 

After analyzing the "Introduction" section, I recommend extending it because in my opinion it is too laconic. Additionally, the selected literature is no longer relevant (some publications date from 1998 and 2004).

Materials and Methods

Line 53-55: According to the art of biomechanical research, patients should be accurately described. I recommend attaching a table describing the most important patient characteristics such as age, weight, height, wheelchair experience / number of years of practicing sports. Later in the chapter, the authors described how they classified patients. That is why I am much more concerned with collecting this information in the form of a table.

 

Line 65-67: What was and what did the "neurological physical examination" look like? I am not a medic like many Applied Sciences readers, so please explain.

 

Line 68-75: Please add a drawing showing the places on the body being performed "physical examination". I propose to present the described scales in tabular form. They will be more readable. In the following paragraphs, the authors quote further used measurement scales. Therefore, they should summarize them in one collective table describing the type of scale, the scale ranges and what it is used for.

 

Line 84-86: This is where it's best to add a math formula that matches the description you just quoted.

 

Line 92: Not written how was the speed of the wheelchair measured using the encoders? Measuring distance and time?

 

Summarizing, the section requires some corrections. It is necessary to add diagrams to facilitate the interpretation of the text describing the method of taking measurements. Moreover, there is no clear definition of the measured parameters and how they are processed during the analysis of the results.

 

Results

Line 119: Authors must classify athletes using the table here or in the methods section

 

Line 131: Results are presented too broadly as summarized, please include the results of the tests performed for individual patients.

 

Figure 3: Signatures under the axes are too small.

 

Line 148-150: Again, I request that you include the results for individual patients. It will certainly be valuable to other researchers, including me.

Table 1: It is difficult to interpret. It does not clearly show what the correlation is between. Do I understand correctly that at the intersection of the column and row there is a correlation value for the parameters that define the column and row?

 

Discussion

Line 169-171: Based on what were the results?

[1] (2020). Biomechanical Relationships Between Manual Wheelchair Steering and the Position of the Human Body's Center of Gravity. Journal of biomechanical engineering, 142(8).

[2] (2020, February). Methods for measuring the position of the centre of gravity of an anthropotechnic human-wheelchair system in dynamic conditions. In IOP Conference Series: Materials Science and Engineering (Vol. 776, No. 1, p. 012062). IOP Publishing.

[3] (2018). Sprint performance and propulsion asymmetries on an ergometer in trained high‐and low‐point wheelchair rugby players. Scandinavian journal of medicine & science in sports, 28(5), 1586-1593.

 

Line 182-183: I agree with the authors' statement that from such a broad research perspective, the article is new. All the more, the authors should take into account the amendments so that the published article will benefit the scientific community dealing with devices supporting people with motor disabilities.

 

To sum up the section, it is very laconic again. The authors have carried out a number of studies, the synthetic results of which should be cited here.

 

Conclusions

I suggest that the authors add further research plans. And as a researcher in a similar area of science, I urge them to do the same research for wheelchairs for everyday use on non-athletes. It would be particularly interesting to compare a classic wheelchair with a wheelchair modified like this:

[1] Impact of a hybrid assisted wheelchair propulsion system on motion kinematics during climbing up a slope. Applied Sciences, 10(3), 1025.

Author Response

The article deals with the important topic of the influence of a technical device on the human body. In manual wheelchairs, adverse effects on the skeletal and muscular systems are common. Therefore, one should strive to minimize such pathological interactions.

Introduction

The authors narrowly defined the area in which they carry out their research. I propose to provide the reader with a broader description of the available technical means and methods of biomechanics diagnostics of anthropotechnical systems. Below are my suggestions for changes. 

Line 38-43: The authors describe the merits of field testing which are beyond dispute. It is worth additionally describing the possibility of implementation on specialized research positions. Such stands simulate field conditions and additionally measure various biomechanical parameters. Additionally, you can introduce the reader what parameters are measured during the tests. In my opinion, the wording "skill tests" is too general and incomprehensible to the reader. Below are some examples of bench tests that measure various biomechanical parameters.

[1] (2019). Effects of the performance parameters of a wheelchair on the changes in the position of the centre of gravity of the human body in dynamic condition. PloS one, 14(12), e0226013.

[2] (2021). The symmetric nature of the position distribution of the human body center of gravity during propelling manual wheelchairs with innovative propulsion systems. Symmetry, 13(1), 154.

[3] (2021). The Impact of the Human Body Position Changes During Wheelchair Propelling On Motion Resistance Force. Journal of Biomechanical Engineering.

[4] (2019) Problems of dynamometer construction for wheelchairs and simulation of push motion. In MATEC Web of Conferences (Vol. 254, p. 01006). EDP Sciences.

[5] (2020). Biomechanical Relationships Between Manual Wheelchair Steering and the Position of the Human Body's Center of Gravity. Journal of biomechanical engineering, 142(8).

Answer:  Thank you for your observations and bibliographic suggestions. We had not talk about the variation of the different biomechanical parameters during the skills test to avoid adding too many parameters non included in the study’s aim, since these data were not part of assessed outcome measures.

The objective of a skill test is clinical, since wheelchair skill performance is defined as “‘the ability to move around and overcome obstacles encountered when carrying out daily activities or social roles in a self-propelled wheelchair”. Therefore the description of biomechanical parameters is beyond the scope of the study. However, we expanded skill tests’ explanation and added the relative references (see lines 41-52) as required.

 

 

Line 44-46: I partially agree with the authors because the effects of wheelchair use on the skeletal system are poorly studied. However, in general terms, i.e. the impact of a wheelchair on the skeletal-muscular system, there are many studies. I recommend informing the reader about this in the introduction. Below are some examples of research works in this field.

[1] (2020). Impact of a hybrid assisted wheelchair propulsion system on motion kinematics during climbing up a slope. Applied Sciences, 10(3), 1025.

[2] (2020). Evaluation of the Biomechanical Parameters of Human-Wheelchair Systems during Ramp Climbing with the Use of a Manual Wheelchair with Anti-Rollback Devices. Applied Sciences, 10(23), 8757.

Answer:  Thank you for your observations and bibliographic suggestions. We modified the sentence and inserted the relative references.

 

After analyzing the "Introduction" section, I recommend extending it because in my opinion it is too laconic. Additionally, the selected literature is no longer relevant (some publications date from 1998 and 2004).

 

Materials and Methods

Line 53-55: According to the art of biomechanical research, patients should be accurately described. I recommend attaching a table describing the most important patient characteristics such as age, weight, height, wheelchair experience / number of years of practicing sports. Later in the chapter, the authors described how they classified patients. That is why I am much more concerned with collecting this information in the form of a table.

Answer: Table 1 was added in the Results section.

 

Line 65-67: What was and what did the "neurological physical examination" look like? I am not a medic like many Applied Sciences readers, so please explain.

Answer: Classical neurological physical examination in spinal cord injury (SCI) is performed through the AIS examination. Deepen the physical exam of the athletes is beyond the purpose of the study. However, a brief description of AIS examination and the relative reference were added (lines 77-82).

 

Line 68-75: Please add a drawing showing the places on the body being performed "physical examination". I propose to present the described scales in tabular form. They will be more readable. In the following paragraphs, the authors quote further used measurement scales. Therefore, they should summarize them in one collective table describing the type of scale, the scale ranges and what it is used for.

Answer: As reported above, AIS is a routinely scale used by physicians in evaluation of patients with SCI and it allows a complete neurological physical examination of upper limbs, lower limbs and sacral region. For details, please read the reference n. 21. Moreover, a brief description of IWRFC was added (with reference n. 20)

 

Line 84-86: This is where it's best to add a math formula that matches the description you just quoted.

 Answer: A brief description of USPRS score is included in the text. For more information please refer to the reference n. 22.

 

Line 92: Not written how was the speed of the wheelchair measured using the encoders? Measuring distance and time?

 Answer: This is a clinical study, therefore, since there are different evaluation methods (clinical, ultrasonographic, skill assessment), we reported only the outcome parameters that are useful to the study’s purpose.

 

Summarizing, the section requires some corrections. It is necessary to add diagrams to facilitate the interpretation of the text describing the method of taking measurements. Moreover, there is no clear definition of the measured parameters and how they are processed during the analysis of the results.

 Answer: As described in the text the assessment measures were: shoulder physical examination through Physical Examination Shoulder Score (PESS), ultrasonographic evaluation with Ultrasound Shoulder Pathology Rating Scale (USPRS), time required to complete 20 m sprint and a 30 m figure eight sprint tests.

 

Results

Line 119: Authors must classify athletes using the table here or in the methods section

 Answer: Table 1 was added.

 

Line 131: Results are presented too broadly as summarized, please include the results of the tests performed for individual patients.

 Line 148-150: Again, I request that you include the results for individual patients. It will certainly be valuable to other researchers, including me.

Answer: According to the previous literature we presented the mean values and standard deviations for each test. Including all data for each athlete and assessed parameters would be chaotic and difficult to read and to interpret.

 

Figure 3: Signatures under the axes are too small.

Answer: Figure 3 was modified as required.

 

Table 1: It is difficult to interpret. It does not clearly show what the correlation is between. Do I understand correctly that at the intersection of the column and row there is a correlation value for the parameters that define the column and row?

Answer: Thank you for your consideration. That is correct. We modified the structure of the table to make it more understandable.

 

Discussion

Line 169-171: Based on what were the results?

[1] (2020). Biomechanical Relationships Between Manual Wheelchair Steering and the Position of the Human Body's Center of Gravity. Journal of biomechanical engineering, 142(8).

[2] (2020, February). Methods for measuring the position of the centre of gravity of an anthropotechnic human-wheelchair system in dynamic conditions. In IOP Conference Series: Materials Science and Engineering (Vol. 776, No. 1, p. 012062). IOP Publishing.

[3] (2018). Sprint performance and propulsion asymmetries on an ergometer in trained high‐and low‐point wheelchair rugby players. Scandinavian journal of medicine & science in sports, 28(5), 1586-1593.

 Answer: the sentence is based on the comparison between the Ultrasound Shoulder Pathology Rating Scale (USPRS) of the non dominant shoulder (USPRS ND in Table 2c) and the 20 m Sprint and Figure 8  Sprint tests. We added the relative sentence in the text.

 

Line 182-183: I agree with the authors' statement that from such a broad research perspective, the article is new. All the more, the authors should take into account the amendments so that the published article will benefit the scientific community dealing with devices supporting people with motor disabilities.

To sum up the section, it is very laconic again. The authors have carried out a number of studies, the synthetic results of which should be cited here.

Answer: we have expanded the discussion and added the related bibliographical references. Moreover, limits were reviewed and implemented.

 

 

Conclusions

I suggest that the authors add further research plans. And as a researcher in a similar area of science, I urge them to do the same research for wheelchairs for everyday use on non-athletes. It would be particularly interesting to compare a classic wheelchair with a wheelchair modified like this:

[1] Impact of a hybrid assisted wheelchair propulsion system on motion kinematics during climbing up a slope. Applied Sciences, 10(3), 1025.

Answer: we added future suggestions.

Round 2

Reviewer 2 Report

The authors took into account the comments and modified the article. I agree with their responses to my comments. 

Author Response

We thank you for your kind response.