Chronological Evaluation of Gait Ability and Posture Balance after Adult Spinal Deformity Surgery

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this interesting manuscript. Authors have carried out a good job. However, some concerns may be resolved.

In abstract. It would be interesting start with a sentence about background. 

Introduction. I consider that it is very poor. Only 10 references in 13 lines?? I recommend improving this section. Authors can incorporate epidemiological data of ASD, examples of ASD, types of surgery, types of rehabilitation,... In addition, a third paragraph with previous references to gait and balance assessment in ASD.

In methods, please describe more and provide reliability and confidence data about tests used.

In table 3, replace "-70" and "76-" by "<70" and ">76".

Please increase the conclusion section and the number of references.

This article is interesting. The major concern is to increase "Introduction".

 

Author Response

To Reviewer 1

Thank you for the opportunity to review this interesting manuscript. Authors have carried out a good job. However, some concerns may be resolved.

In abstract. It would be interesting start with a sentence about background. 

 

Thank you for your valuable comment. We added the sentences as follows.

Adult spinal deformity (ASD) is highly prevalent in persons older than 65 years, affecting more than 30% of total population. There are many important reports which describe excellent postoperative results for ASD surgery. However, there is no report which describes chronological evaluation of gait ability and spinal balance after ASD surgery.

 

Introduction. I consider that it is very poor. Only 10 references in 13 lines?? I recommend improving this section. Authors can incorporate epidemiological data of ASD, examples of ASD, types of surgery, types of rehabilitation,... In addition, a third paragraph with previous references to gait and balance assessment in ASD.

 

We appreciate your important comments. We added the sentences in the introduction part.

In the world, population is rapidly increasing because of increased longevity, improved medical care, and declining natality [1,2]. This global population shifts have affected the prevalence of musculoskeletal diseases such as adult spinal deformity (ASD). ASD is highly prevalent in persons older than 65 years, affecting more than 30% of total population [3,4]. ASD is caused by spinal malalignment, which results in not only severe low back pain and neurological dysfunction but also reflux esophagitis, cosmetic disorders, and mental disorders [5,6].

A large number of reports supports the effectiveness of surgical treatment over conservative treatment in severe cases [7,8]. The goal of ASD surgery is to restore the global spinal balance without any complications, especially sagittal alignment [9,10]. However, it needs several months for the elderly ASD patients to adopt a new posture. The rehabilitation after ASD surgery is very important to regain normal daily life activity for the ASD patients to avoid falls because of spinal imbalance [11]. There are many important reports which describe excellent postoperative results for ASD surgery [12,13].

The systematic review revealed complex rehabilitation reduces short and long-term disability and fear avoidance behavior following lumbar fusion surgery [14], and the rehabilitation for ASD resulted in significant functional improvements [15]. Recently, gait analysis including timed up and go test (TUG) was reported as a very useful tool to evaluate patients’ dynamic balance [16-18]. However, there is no report which describes chronological evaluation of gait ability and spinal balance after ASD surgery. We made a hypothesis as patients’ gait ability and posture balance will recover gradually and independently after surgery. With those results, the rehabilitation staff can provide patients appropriate rehabilitation program according to the recovery of gait ability and posture balance. The present prospective study aimed to determine their recovery time of gait and spinal balance ability after ASD surgery.

 

In methods, please describe more and provide reliability and confidence data about tests used.

In table 3, replace "-70" and "76-" by "<70" and ">76".

 

Thank you for your comment.

We changed as you mentioned.

The 10-meter walk test is a commonly used measure for assessing walking speed [19]. Distances were provided at the beginning and end of the timed walkway to allow participants space to accelerate/decelerate outside the data collection area to help reduce gait variability introduced during these phases [20]. The average walking velocity according to the age are 1.34-1.24 m/s(60-69 years old), 1.26-1.13 m/s (70-79 years old), and 0.97-0.94 m/s (80-99 years old) [21]. The excellent reliability of this test has been reported [22].

 

Right and left single leg stand tests were performed with the eye open as a static balance test.

TUG has a wide variety of clinical use making it a diverse measure that should be considered when choosing an activity-based outcome. The excellent reliability and validity of TUG as a clinical tool has been reported in a systematic review [24].

 

Please increase the conclusion section and the number of references.

This article is interesting. The major concern is to increase "Introduction".

We appreciate your comment.

We added the refences and changed the conclusion as follows;

 

Chronological evaluation of gait and posture balance analysis after ASD surgery revealed that ASD patients could not recover gait and posture balance ability one month after surgery. However, at 12 months after surgery, gait ability and dynamic posture balance became better than preoperative level, but static posture balance was the same level of preoperative status. Rehabilitation staff and patient-support personnel should pay special attention to patients’ static balance within 12 months after ASD surgery.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Thank you for the opportunity to review this study. I find the topic to be very important and timely, and the results of the study bring some novelty (although this could be made more explicit). On the other hand, there are some drawbacks that must absolutely be addressed before the study could be considered for publication.

 

Introduction:

• Line 44-45. This very vaguely stated, could you elaborate with some more details what these [6,7] references are about?
• Include a hypothesis
• Include 1-2 sentences somewhere at the end of the introduction regarding what your results will bring for clinical practice and/or further research. The novelty/rationale for the study could also be stated more explicitly

Methods:

• I see no point for male female count in Table 1, why not just state in the text that all participants were female?
• Given that there is extra space, please also include minimal and maximal values in Table 1
• I honestly see no point in including tables 2 and 3 for normative values. This can be stated in the text or not at all. And the values for younger population are not really relevant.
• Static balance test needs more description – position of arms, instruction, how many repetitions (+ did you take mean or best), shod or barefoot, etc.
• If you performed more than 1 trial for your assessment, it would be good to know the reliability (i.e., rep-by-rep consistency) of your measurement

Statistics:

• Was normality of the data violated or you used the non-parametric tests for some other reason? Please clarify
• Please include some measure of effect size for your comparison

Results:

• Line 128 we are referred to the Table 5, but there are no correlation coefficients available. Please provide these either in the text or as a table. Moreover, I think you should also attempt to correlate relative changes in each of the parameters

Discussion:

• Line 173 and 185 contain some superscript references – please check and amend if needed
• Line 165-166 could be more explicit – what exactly did they report (e.g., correlation?)
• Limitations: also that you did not use gold standard (force plates) for static balance assessments
• In conclusions, maybe add a sentence about what the next logical research steps are (Future studies should….)
• Line 178, for [19], this reference might be more appropriate: 10.3390/diagnostics10090667

Minor issues:

• Line 42-44 seem a bit oddly phrased, should it be “… AND to avoid falls” ?
• Table 4: the body height data is repeated, not necessary

Author Response

To Reviewer 2

 

Thank you for the opportunity to review this study. I find the topic to be very important and timely, and the results of the study bring some novelty (although this could be made more explicit). On the other hand, there are some drawbacks that must absolutely be addressed before the study could be considered for publication.

 

Introduction:

1. Line 44-45. This very vaguely stated, could you elaborate with some more details what these [6,7] references are about?
2. Include a hypothesis
3. Include 1-2 sentences somewhere at the end of the introduction regarding what your results will bring for clinical practice and/or further research. The novelty/rationale for the study could also be stated more explicitly

 

We appreciate your thoughtful comments.

We changed the sentences as follows.

 

1. A large number of reports supports the effectiveness of surgical treatment over conservative treatment in severe cases [7,8].
2. We made a hypothesis as patients’ gait ability and posture balance will recover gradually and independently after ASD surgery .
3. With those results, the rehabilitation staff can provide patients appropriate rehabilitation program according to the recovery of gait ability and posture balance.

 

Methods:

4. I see no point for male female count in Table 1, why not just state in the text that all participants were female?
5. Given that there is extra space, please also include minimal and maximal values in Table 1
6. I honestly see no point in including tables 2 and 3 for normative values. This can be stated in the text or not at all. And the values for younger population are not really relevant.
7. Static balance test needs more description – position of arms, instruction, how many repetitions (+ did you take mean or best), shod or barefoot, etc.
8. If you performed more than 1 trial for your assessment, it would be good to know the reliability (i.e., rep-by-rep consistency) of your measurement

 

Thank you for your valuable comments.

We changed the sentences as follows.

 

4. We changed Table 1.
5. We changed as you mentioned.
6. We changed as you mentioned.
7. We added figures according to your suggestion.

Patients were instructed to stand single leg, face is straight, both arms are side of the body, with shoes. The test was performed twice and the average values were taken.

8. Because the patients are very old, so we think more than twice tests are not suitable.

 

Statistics:

9. Was normality of the data violated or you used the non-parametric tests for some other reason? Please clarify
10. Please include some measure of effect size for your comparison

 

We appreciate your important comments.

We changed the sentences as follows.

 

9. We performed Shapiro-wilk normality test histogram for the values. The result was not a normal distribution because of small number of the patients.
10. P<0.05 was considered statically significant.

 

Results:

11. Line 128 we are referred to the Table 5, but there are no correlation coefficients available. Please provide these either in the text or as a table. Moreover, I think you should also attempt to correlate relative changes in each of the parameters

 

Thank you for your thoughtful comments.

11.We added a new table (Table 4).

	SVA RR	PI-LL RR	LL RR	PT RR
10-meter walk velocity	-0.1323	0.3444	0.2737	-0.0564
Timed up and go test	-0.0752	0.3714	0.1729	-0.0113
Single leg standing (right side)	-0.1077	-0.1502	0.2018	0.0843
Single leg standing (left side)	-0.1366	-0.0197	0.1199	-0.0425

 

 

 

 

Discussion:

12. Line 173 and 185 contain some superscript references – please check and amend if needed
13. Line 165-166 could be more explicit – what exactly did they report (e.g., correlation?)
14. Limitations: also that you did not use gold standard (force plates) for static balance assessments

 

We appreciate your important comments.

 

12. We corrected as you mentioned.
13. We changed the sentence as follows.

Miyazaki et al, reported the loss of lumbar lordosis related to loss of leg strength for walking ability in elderly ASD patients [5,15].

14..We added the sentence as follows.

We didn’t use force plates to evaluate patients’ balance.

 

In conclusions, maybe add a sentence about what the next logical research steps are (Future studies should….)

15. Line 178, for [19], this reference might be more appropriate: 10.3390/diagnostics10090667

 

We appreciate your thoughtful comments.

15..We added the reference according to your advice [19,X]

X: 10.3390/diagnostics10090667

 

Minor issues:

Line 42-44 seem a bit oddly phrased, should it be “… AND to avoid falls” ?

Table 4: the body height data is repeated, not necessary

 

We changed those as you mentioned.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Thank you for your responses.

Reviewer 2 Report

Thank you for the amendments. I suggest you change the decimal places to 2 (e.g., 0.25) for correlation coefficients in the new table. Other than that, I have no further comments and the paper can be accepted for publication.