Conventional Cervical Exercises Compared with a Mixed-Reality-Based Game in Asymptomatic Subjects: An Exploratory Crossover Pilot Study

Round 1

Reviewer 1 Report

The topic of this paper is very interesting and it should be studied in future educational research and other review or overview.

Introduction

I recommend that you highlight in more detail the novelty of the study in correlation with previous studies.

Conclusion

I recommend that you review and expand on the conclusion to highlight the most relevant results of your study.

Author Response

Reviewer #1:

 

Response: Thanks for your important comments to improve the quality of the manuscript. Some significant modifications have been carried out according to your suggestions. Thank you.

 

Comments and Suggestions for Authors

The topic of this paper is very interesting, and it should be studied in future educational research and other review or overview.

 

Introduction

 

I recommend that you highlight in more detail the novelty of the study in correlation with previous studies.

 

Response: Thank you for the comment. We added a new paragraph in the introduction to explain the reader the need for this research and which together with the previous studies we have carried out, makes the need for this study even clearer.

 

The paragraph: “Different studies indicate that subjects with neck pain may present coordination alterations in the synergy between the activity of the deep and superficial cervical flexor musculature, as well as a decrease in the activity of this deep musculature, accompanied by fatigability and a delayed activation of the same, which may result in a diminished capacity in the control of the deep flexor and extensor muscles. Alterations in cervical movement and motor control appear more frequently in patients with neck pain than in healthy subjects. This opens the possibility of using VR, MR or AR with the aim of im-proving these outcomes. Currently, there….”

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Title:

I would strongly advise the authors to revise the name of the article. Reading the name of a product in the title sounds like advertising to me, I would advise to remove the product name throughout the whole article and add the name of the used hardware only in a separate "Apparatus" section. In this section, the authors should describe which hardware was used.

 

Introduction:

 I like the idea behind the introduction. However, some sentences have a bitter aftertaste to me. For example, line 59 where it is stated that Hololens is one of the first mixed reality headset. I would respectfully disagree and say that Hololens is an AR headset.

Also line 49 to 59 references Brigham [1] multiple times and it seems quite clear that this is the only "source of information" about AR, VR, and MR. I would suggest the authors to take a look at Schäfer et al. [2] and maybe add another source to foster the understanding of MR. For example, Schäfer et al. [2] uses Milgram et al.’s [3] definition of the Reality-Virtuality continuum, which is widely known and explains that MR is either a combination of AR and VR elements or uses real world objects to interact with the virtual world.

I would strongly suggest to revise this section and also add more sources of information regarding AR, VR, MR as done in [2] or [3].

 

It should also be explained what the cervico-craniofacial region is. I would also like to see an image accompanying the explanation. Additionally, it is not clear to the reader why it is important to do research on the cervico-craniofacial region.

 

Materials and Methods:

I dont like that the chapter starts with the sentence " This was a study…" which comes directly after the introduction section. It is not yet clear what has been done yet and then it is already described that there was a study conducted. What was the purpose of the study? It is not clear to this point.

 

I would recommend to rewrite part of this section. For example, as introduction sentence I would expect something like "In order to achieve (or analyze) XYZ, a user study was conducted." Additionally,  line 98 - 102 should be placed at the bottom of the manuscript (In the "Institutional Review Board Statement" section which is in the template).

Before explaining the experiment, it should be explained how the game was implemented and what the game is actually about. If the game was not implemented by the authors (what I think is the case), it should be explained why that game is suitable for conducting the experiment and maybe why other similar games were not chosen..

 

Line 119: Some unnecessary information such as that "Graphpad" was used which is not really necessary to understand the paper (this sounds again like advertising).

 

Line 149: instead of 4 mts x 2 mts it can be simply written " 4m x 2m"

 

Also I would suggest the author to read [4] about MR.

 

I like chapter 3 and 4.

 

Other notes:

Line 106: I don't think it is important when users were recruited

 

Typos and errors:

Line 107: "Subjects must fulfilled" -> wrong grammar

 

References:

 

[1] Brigham, Tara J. "Reality check: basics of augmented, virtual, and mixed reality." Medical reference services quarterly 36.2 (2017): 171-178.

 

[2] Schäfer, Alexander, Gerd Reis, and Didier Stricker. "A Survey on Synchronous Augmented, Virtual and Mixed Reality Remote Collaboration Systems." arXiv preprint arXiv:2102.05998 (2021).

 

[3] Milgram, Paul, et al. "Augmented reality: A class of displays on the reality-virtuality continuum." Telemanipulator and telepresence technologies. Vol. 2351. International Society for Optics and Photonics, 1995.

 

[4] Speicher, Maximilian, Brian D. Hall, and Michael Nebeling. "What is mixed reality?." Proceedings of the 2019 CHI conference on human factors in computing systems. 2019.

Author Response

Reviewer #2:

 

I would strongly advise the authors to revise the name of the article. Reading the name of a product in the title sounds like advertising to me, I would advise to remove the product name throughout the whole article and add the name of the used hardware only in a separate "Apparatus" section. In this section, the authors should describe which hardware was used.

 

Response: We changed across the manuscript. Except in the “Materials and Methods” section.

 

 

 

Introduction:

 

I like the idea behind the introduction. However, some sentences have a bitter aftertaste to me. For example, line 59 where it is stated that Hololens is one of the first mixed reality headset. I would respectfully disagree and say that Hololens is an AR headset.

 

Response: we have added “ Hololenst that is an MR headset”

 

Also line 49 to 59 references Brigham [1] multiple times and it seems quite clear that this is the only "source of information" about AR, VR, and MR. I would suggest the authors to take a look at Schäfer et al. [2] and maybe add another source to foster the understanding of MR. For example, Schäfer et al. [2] uses Milgram et al.’s [3] definition of the Reality-Virtuality continuum, which is widely known and explains that MR is either a combination of AR and VR elements or uses real world objects to interact with the virtual world.

 

I would strongly suggest to revise this section and also add more sources of information regarding AR, VR, MR as done in [2] or [3].

 

Response: we have added the following sentence: “On the other hand, a previous pilot study concluded that adding virtual reality to kinesthetic exercises did not further improve range of motion, speed and accuracy of movement [4]. Other work has shown that virtual reality increases the improvement of rotational range of motion in both healthy subjects and patients with neck pain[5].”

 

 

It should also be explained what the cervico-craniofacial region is. I would also like to see an image accompanying the explanation. Additionally, it is not clear to the reader why it is important to do research on the cervico-craniofacial region.

 

Response: Thank you for your comment, because thanks to it we have detected a mistake in expressing what we wanted to say. On the one hand, the most correct term would be cervical region and spine. And on the other hand, we added a new paragraph to explain the reader the need for this research.

 

The paragraph: “Different studies indicate that subjects with neck pain may present coordination alterations in the synergy between the activity of the deep and superficial cervical flexor musculature, as well as a decrease in the activity of this deep musculature, accompanied by fatigability and a delayed activation of the same, which may result in a diminished capacity in the control of the deep flexor and extensor muscles. Alterations in cervical movement and motor control appear more frequently in patients with neck pain than in healthy subjects. This opens the possibility of using VR, MR or AR with the aim of im-proving these outcomes. Currently, there….”

 

 

Materials and Methods:

 

I dont like that the chapter starts with the sentence " This was a study…" which comes directly after the introduction section. It is not yet clear what has been done yet and then it is already described that there was a study conducted. What was the purpose of the study? It is not clear to this point.

 

Response: We have followed the CONSORT (CONsolidated Standards of Reporting Trials) methodological guide and in this guide, they recommend ending the introduction with the objectives of the study and beginning the material and method with the type of study that has been carried out.

 

 

I would recommend to rewrite part of this section. For example, as introduction sentence I would expect something like "In order to achieve (or analyze) XYZ, a user study was conducted." Additionally, line 98 - 102 should be placed at the bottom of the manuscript (In the "Institutional Review Board Statement" section which is in the template).

 

Response: Changed to: “In order to achieve the above-mentioned objectives, a study a randomized single-blind crossover pilot study was carried out”. Additionally, we move the lines 98-102 to the bottom of the manuscript as the template suggest.

 

Before explaining the experiment, it should be explained how the game was implemented and what the game is actually about. If the game was not implemented by the authors (what I think is the case), it should be explained why that game is suitable for conducting the experiment and maybe why other similar games were not chosen.

 

Response: we changed and added content to the paragraph:

 

“The application used was RoboRaid software; a first-person “shooter” game, for general users, which requires cervical movements to move the pointer. This application was chosen among others because it allowed free movement of the cervical spine in all 3 planes of motion in addition to the free movement of the rest of the body. Making the subject perform movements during the study as functional as possible.”

 

Line 119: Some unnecessary information such as that "Graphpad" was used which is not really necessary to understand the paper (this sounds again like advertising).

 

Response: we have deleted it

 

Line 149: instead of 4 mts x 2 mts it can be simply written " 4m x 2m"

 

Response: we have changed it as suggested

 

Also I would suggest the author to read [4] about MR. I like chapter 3 and 4.

 

Response: Thank you so much for the references and the overall comments.

 

 

Other notes:

 

Line 106: I don't think it is important when users were recruited

 

Response: Thank you for your comment, I agree but we would like to leave it for the future, to record the year in which the work was carried out.

 

Typos and errors:

 

Line 107: "Subjects must fulfilled" -> wrong grammar

 

Response: we have added the following expression “Subjects must meet”

 

 

 

References:

 

 

[1] Brigham, Tara J. "Reality check: basics of augmented, virtual, and mixed reality." Medical reference services quarterly 36.2 (2017): 171-178.

 

 

 

[2] Schäfer, Alexander, Gerd Reis, and Didier Stricker. "A Survey on Synchronous Augmented, Virtual and Mixed Reality Remote Collaboration Systems." arXiv preprint arXiv:2102.05998 (2021).

 

 

 

[3] Milgram, Paul, et al. "Augmented reality: A class of displays on the reality-virtuality continuum." Telemanipulator and telepresence technologies. Vol. 2351. International Society for Optics and Photonics, 1995.

 

 

 

[4] Speicher, Maximilian, Brian D. Hall, and Michael Nebeling. "What is mixed reality?." Proceedings of the 2019 CHI conference on human factors in computing systems. 2019.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

More mistakes were added with the revised manuscript:

Line 59: It is mentioned twice that Hololens is a MR headset (in once sentence)

Line 111: …A study a randomizhed ….

 

I would suggest to use https://www.deepl.com/translator  which is very good in translating/producing scientific english sentences (Im not affiliated in any way)

 

I read your main source for MR definition and explanation (Brigham et al.) and it lines up with what you write in the paper. However, I want to emphasize again that this will lead to confusion to readers of the manuscript (Especially experts in tghe field of AR, VR and MR). I don't think many people grasp what MR is and many times MR is the same as AR. Giving a virtual object perspective and depth, anchoring a virtual object in the physical world …all of this is essential for AR, yet the author (Brigham et al.) says it is exclusive for MR. Therefore, I would suggest you to read the papers I recommended in my first review (at least parts of it) and add information in your manuscript.

 

I'm not trying to be rude, I just want to improve the manuscript for your and the readers sake.

 

The other points are fine now.

Author Response

Responses to Reviewers' comments Second Round:

 

Reviewer 2

 

 

Comments and Suggestions for Authors

 

More mistakes were added with the revised manuscript:

 

Line 59: It is mentioned twice that Hololens is a MR headset (in once sentence)

 

Response: we have deleted it and correct it as follow: “As an example, there is the “Microsoft© Hololens”, that is an MR headset”

 

Line 111: …A study a randomizhed ….

 

 

Response: I have correct it

 

I would suggest to use https://www.deepl.com/translator  which is very good in translating/producing scientific english sentences (Im not affiliated in any way)

 

 

 

 

I read your main source for MR definition and explanation (Brigham et al.) and it lines up with what you write in the paper. However, I want to emphasize again that this will lead to confusion to readers of the manuscript (Especially experts in tghe field of AR, VR and MR). I don't think many people grasp what MR is and many times MR is the same as AR. Giving a virtual object perspective and depth, anchoring a virtual object in the physical world …all of this is essential for AR, yet the author (Brigham et al.) says it is exclusive for MR. Therefore, I would suggest you to read the papers I recommended in my first review (at least parts of it) and add information in your manuscript.

 

I'm not trying to be rude, I just want to improve the manuscript for your and the readers sake.

 

Thank you again for this comment. You are right, we don’t take as a rude comment.

 

We remake the paragraph of the introduction to:

The most used technologies in rehabilitation are virtual reality (VR), augmented reality (AR), and mixed reality (MR) devices [3]. The “boom” of these devices in recent years is due to the increase of VR games and head-coupled immersive virtual reality devices in 2006. However, international experts agree on the differences between VR on the one hand, and AR-MR on the other hand[4]. VR does not interact with the real environment, the user interaction is always with a virtual environment [3–5]. AR and MR allow the user to see real objects and the environment in which they are placed adding virtual and responsive objects on top of it . Some experts believe that the addi-tion of the MR on the AR, among other things, is giving virtual objects perspective and depth [3–5]. Nevertheless, public accessibility to MR is limited because of the high prices of the devices, among other limitations [3]. As an example of MR, according to some experts, is the “Microsoft© Hololens” headset device[4] . 

 

 

Author Response File: Author Response.pdf