Rehabilitation of Patients with Moderate Knee Osteoarthritis Using Hyaluronic Acid Viscosupplementation and Physiotherapy

Round 1

Reviewer 1 Report

The manuscript by Onu and co-workers investigate on the role of hyaluronic acid viscosupplementation and physiotherapy on a number of patients suffering from knee osteoarthritis. The subject is of interest. The study has been properly designed and results are interesting. However, there are some important concerns that make the manuscript not suitable for publication.

 

Some questions to be solved are:

 

Introduction:

The use of subheading in the Introduction section should be re-considered. Perhaps it should be better to remove the two subheads included in lines 113 and 145, respectively.

 

Materials and Methods

Authors should include a CONSORT diagram describing details of the population recruitment, etc.

 

Authors do not include statistical treatment of results. No proper conclusions can be done without a serious statistical analysis.

 

Discussion

Authors include in the manuscript 5 paragraphs under the subject of Discussion. However, authors do not discuss results but better include a summary of the results. Without a proper discussion, this manuscript cannot be published.

Author Response

We have removed subheadings 113 and 145.
We have included the CONSORT diagram describing details of the enrollment, intervention, follow-up, and data analysis.
The statistical treatment of the results was also included to highlight the results of the study for the two groups of patients.
The discussions were extended and modified to highlight the results that the two groups achieved, emphasizing the importance of using physiotherapy in the recovery of patients with Knee Osteoarthritis.

Author Response File: Author Response.docx

Reviewer 2 Report

The study title is focused on the rehabilitation of patients with moderate knee osteoarthritis using hyaluronic acid viscosupplementation and physioterapy. This is a very interesting topic to search possibilities to treat OA patients and to prepare new rehabilitation standards. There are data that should be added to this type study

1. Please add information about the including patients with bilateral OA especially when opposite knee OA is more advanced. Usually this patient should be excluded.
2. Line 271 – NSAIDs were excluded, please describe about the patient rescue medication in case not sufficient improvement. There could be the risk of patients withdrawal from the study if not effective treatment
3. Line 284 – please describe with more details PTE you used. Study should be described with data that allows to repeat your technique or to use it in the new standard preparation.
4. Please add all limitations of the study.
5.  Please rewrite conclusions. There are more interesting data in your study to show to your readers.

Author Response

We added key information about the inclusion of patients with bilateral KOA, emphasizing that only the symptomatic knee was treated with viscosupplementation with hyaluronic acid and physiotherapy. Patients with both symptomatic knees were excluded from the study.
We have added information about backup medication for the two groups of patients in case of insufficient improvement.
We have added the treatment schedule used in the PTE in detail, which will allow to repeat the PTE techniques in a new standard preparation.
We completed and modified the conclusions adding the limits of the study.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Authors have improved the manuscript after following recommendations done. However, there are still important flakes to be solved. The main concern is the confusing organization of methods and results sections. In that sense, in the methods sections authors describe many of the results found in the study. On other hand, despite authors have included statistical analyses as requested, there is a lack for a statistical methodology paragraph in methods section. Authors should devote enough time to clearly organize these sections according to recommendations prior to take a decision on acceptance of the manuscript.

Author Response

Point-by-point Response to reviewer’ concerns.

We want to thank the reviewers for their thoughtful comments that resulted in an improved version of the manuscript. Reviewers’ comments are italicized below. Our responses are in normal font. The red text indicates the additions in the revised manuscript.

Reviewer 2.

Point 1. Authors have improved the manuscript after following recommendations done. However, there are still important flakes to be solved. The main concern is the confusing organization of methods and results sections. In that sense, in the methods sections authors describe many of the results found in the study.

We appreciate the reviewer´s comment and we have now reorganized the methods and results sections in the main text.  

 

Point 2. On other hand, despite authors have included statistical analyses as requested, there is a lack for a statistical methodology paragraph in methods section.

 

We agree with the reviewer’s comment, and we have now added the Statistical Approach paragraph and a new reference (48) to the main text (lines 334-342).

“Regarding the statistical methodology approached, the procedure is described in the literature by several authors [48]. Thus, if in a first phase a preliminary statistical description is made, presenting the average values, the standard deviations, and the comparisons between the series of values, in the second phase an evaluation of the correlation coefficients is made. This second step is necessary in order to identify the grouping of the factors that influences the expected result. Finally, the Principal Components Method (PCA) was applied - a procedure based on the use of correlation coefficient values. This last step is enough to highlight the dynamic grouping of the factors that influence the desired result.”

Moreover, a statement about the statistical analysis results were added to the Conclusions section (lines 699-701).

“The statistical analysis showed that in the case of CG the evolution of the parameters that describe the improvement of the results proved to be modest. On the other hand, using t-test methods and PCA analysis, the applied treatment had effective results.”

 

As suggested by the reviewer, we have now carefully checked the English style and typos.

Author Response File: Author Response.docx

Reviewer 2 Report

Accept in present form.

Author Response

We want to thank the reviewers for their thoughtful comments that resulted in an improved version of the manuscript. Reviewers’ comments are italicized below. Our responses are in normal font. The red text indicates the additions in the revised manuscript. 

Round 3

Reviewer 1 Report

Authors have answered most of the concerns. However, there are still the need to check out several some aspects like the headings and legends of some of the tables of the manuscript.