Feasibility of a Novel Movement Preference Approach to Classify Case Complexity for Adults with Non-Specific Chronic Low Back Pain

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper examines the feasibility of a movement preference approach for classifying the complexity of adult cases with nonspecific CLBP.

 

The work is interesting, but I have a few doubts and I ask the authors to clarify them.

 

*Line 55 -Please clarify and expand the description of other diagnostic subgroups, such as the "bio" component.

*The section on materials and methods lacks inclusion and exclusion conditions and a description of who qualified the patients for the project.

*With regard to the participation of therapists with pervasive clinical experience, the conclusion is not fully valid (line 334) because this study lacks young therapists

Author Response

Reviewer 1 comments

1. Line 55 -Please clarify and expand the description of other diagnostic subgroups, such as the "bio" component.

-Responses: We have expanded the description of “bio” component sub-group in the manuscript, cited below.

“While there exists a psychosocial approach to classify case complexity [6, 7], it is important to consider other diagnostic subgroups such as the ‘bio’ component [8] which could be classified into mechanical and non-mechanical pain [9]. Mechanical pain is related to movement disorders while non-mechanical pain is related to pathological conditions such as inflammation [9].” (lines 40 to 44)

Ref 9: O'Sullivan, P.; Waller, R.; Wright, A.; Gardner, J.; Johnston, R.; Payne, C.; Shannon, A.; Ware, B.; Smith, A. Sensory characteristics of chronic non-specific low back pain: A subgroup investigation. Manual therapy 2014, 19, 311-318.

 

2. The section on materials and methods lacks inclusion and exclusion conditions and a description of who qualified the patients for the project.

-Responses: We note that the inclusion and exclusion criteria were unclear in the previous manuscript. We have since revised these criteria, cited below.

“The inclusion criteria were adults aged 21 to 40 years old who could communicate in English, had current pain in the lower back for more than 3 months on most days of the week, and average pain in the past week is ≥4 points rated on the 11-point pain numeric rating scale. Participants were excluded if they were receiving recent exercise intervention (past 3 months) or surgical intervention (past 6 months), having ongoing fever or inflammation, known pregnancy, terminal end-stage illness such as cancer, orthopedic or neurological conditions that required medical management, or recent unexplained weight loss or loss of appetite.” (line 97 to 104)

 

3. With regard to the participation of therapists with pervasive clinical experience, the conclusion is not fully valid (line 334) because this study lacks young therapists

-Responses: We agree with the reviewer that the previous conclusion on clinical experience was not fully valid due to the lack on inexperienced therapists in this study. We have since deleted the irrelevant part and revised the concluding sentence, cited below.

“This objective system can potentially allow clinicians, physiotherapists and other healthcare professionals to identify the complexity of a LBP case and seek help if they are unsure.” (line 322 to 323)

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for giving me the opportunity to review this work.

Unfortunately I have some doubts about several aspects. Overall, the work requires a broad and in-depth formal review. There are several typos and the text should be reviewed by a native English speaker. Furthermore, the main message that the authors want to convey is unclear and the results and conclusions sections are not  supported by the data.

In order to indicate the validity and usefulness of the methodology proposed for the classification of patients with LBP, it would have been interesting to see if patients treated with clinical interventions chosen on the basis of the inclusion in this classification actually have better therapeutic outcomes than those who are not. In its current state, the work  seems more like a protocol study; discussion and conclusions seem rather speculative. The topic is interesting but I would recommend rethinking the objectives of the work and adopting the appropriated methodological measures  in order to convey a message with some scientific resonance.

Furthermore, I would like to highlight some minor points:

- Line 16: what does DMA stands for?

- Line 18-22: it is nor clear what message you're trying to convey. What does it mean that subjects were assessed on their movement preference?

- Line 25-27: how?

- I would suggest, to make the manuscript more readable, to start the introduction by going straight to the topic, avoiding the preamble on physiotherapy.

- characteristics of the sample: how many men and women? age range?

Comments on the Quality of English Language

The text should be reviewed by a native English speaker.

Author Response

Reviewer 2 comments

1. Overall, the work requires a broad and in-depth formal review. There are several typos and the text should be reviewed by a native English speaker. Furthermore, the main message that the authors want to convey is unclear and the results and conclusions sections are not supported by the data.

-Responses: Thank you for your time and effort to review our manuscript. We appreciate your feedback and have since revised manuscript. We have carefully checked and corrected the typos and errors in grammar and punctuation. The main message, results and conclusions have been revised substantially for better coherence. Please see our point-by-point responses below.

 

2. In order to indicate the validity and usefulness of the methodology proposed for the classification of patients with LBP, it would have been interesting to see if patients treated with clinical interventions chosen on the basis of the inclusion in this classification actually have better therapeutic outcomes than those who are not. In its current state, the work seems more like a protocol study; discussion and conclusions seem rather speculative. The topic is interesting but I would recommend rethinking the objectives of the work and adopting the appropriated methodological measures  in order to convey a message with some scientific resonance.

-Responses: Thank you for the insightful comments. We acknowledge that our manuscript is similar to a protocol study to set directions for future studies and did not evaluate the validity of the proposed classification system. As such, we have revised the objectives, methods and results presentation throughout the study to reflect its nature of proposing a new protocol.  Under the Discussion (4.4. Future Directions), we have recommended future studies to check if patients treated with clinical interventions chosen based on the DMA Clinical Pilates classification would have better therapeutic outcomes than those who were not. The key changes are highlighted below:

“The present study proposed a movement-based classification system based on Dance Medicine Australia (DMA) Clinical Pilates for patients with non-specific chronic LBP.” (lines 16 to 17)

“In conclusion, this study has demonstrated that the proposed movement-based classification system was a feasible method for classifying case complexity in adults with non-specific chronic LBP.” (lines 25 to 27)

“Therefore, this study proposed a comprehensive movement-based classification protocol for adults with non-specific chronic LBP.” (lines 89 to 90)

“The present study proposed a new classification system based on the DMA Clinical Pilates approach to classify case complexity for non-specific chronic LBP in physiotherapy practice.” (lines 221 to 223)

“All participants could be classified with the classification system with a successful classification rate of 100%.” (lines 186-187)

“Extending from the present study, it will be interesting to see if patients treated with clinical interventions chosen based on the DMA Clinical Pilates classification would have better therapeutic outcomes than those who were not.” (lines 305 to 307)

 

3. I would like to highlight some minor points:

- Line 16: what does DMA stands for?

-Responses: DMA stands for Dance Medicine Australia. To provide better clarity in the abstract, the sentence has been updated and cited below.

“The present study proposed a movement-based classification system of Dance Medicine Australia (DMA) Clinical Pilates for patients with non-specific chronic LBP.” (line 16 to 17)

 

- Line 18-22: it is not clear what message you're trying to convey. What does it mean that subjects were assessed on their movement preference?

-Responses: Movement preference refers to the movement directions that can relieve pain or are pain-free. We have since updated the sentence to provide better clarity:

“Forty adults with non-specific chronic LBP were assessed on their movement preference (i.e. movement directions that can relieve pain or are pain-free) through the DMA Clinical Pilates method.” (line 17 to 19)

 

- Line 25-27: how?

-Responses: We note that the previous concluding sentence did not fit the flow of the abstract and have deleted it from our revision.

 

- I would suggest, to make the manuscript more readable, to start the introduction by going straight to the topic, avoiding the preamble on physiotherapy.

-Responses: We note the reviewer’s recommendations and have avoided the preamble on physiotherapy. We have removed the irrelevant information and the introduction now starts with the topic of chronic low back pain complexity:

“The management of patients with non-specific chronic low back pain (LBP) is a challenging problem to tackle.” (line 31 to 32)

 

- characteristics of the sample: how many men and women? Age range?

-Responses: Table 1 now includes the range for each variable. The sex distribution of is now included in Section 2.2 and cited below.

“This study is part of a larger study which recruited 40 adults (25 men and 15 women) with non-specific chronic LBP (Table 1).” (lines 96 to 97)

Reviewer 3 Report

Comments and Suggestions for Authors

the authors proposal was identified as a specific tool for what it intends to evaluate and holds scientific quality for practical apllications and future interventions.

Comments on the Quality of English Language

english language with no mistakes detected

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors tried to correct the manuscript appropriately. In this form, the article can be published.

Author Response

The authors tried to correct the manuscript appropriately. In this form, the article can be published.

-Response: Thank you for your time to review our paper.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

thank you for the changes made. However, the fundamental flaws described in the previous report remain. Despite the changes made, I don't see what is the significance of this study, what is the new thing that can drive the field vertically, or how it can, beyond theoretical considerations, be of help in the clinical setting. Hence, I cannot endorse it for publication. As I have already said, I suggest evaluating whether patients treated with clinical interventions chosen on the basis of the inclusion in this classification actually have better therapeutic outcomes than those who are not. This could make some contribution to the clinical management of LBP.

Author Response

Dear authors,

thank you for the changes made. However, the fundamental flaws described in the previous report remain. Despite the changes made, I don't see what is the significance of this study, what is the new thing that can drive the field vertically, or how it can, beyond theoretical considerations, be of help in the clinical setting. Hence, I cannot endorse it for publication. As I have already said, I suggest evaluating whether patients treated with clinical interventions chosen on the basis of the inclusion in this classification actually have better therapeutic outcomes than those who are not. This could make some contribution to the clinical management of LBP.

-Response: Thank you for your time to review our revision. We apologize that we did not make clear the significance and novelty of our study in the earlier version. We have since revise the Introduction to provide more information on the current pitfalls in the management of low back pain in clinical practice. To improve the current practice (e.g. patients bearing pain during exercise in the psychosocial approach), it is necessary to consider an alternative approach. As such, we proposed a novel concept of using DMA Clinical Pilates as a classification method to provide physiotherapist a gauge on the complexity of a case. Our paper presented not only the theoretical framework but also used 40 low pack pain cases to test out if the proposed method will work. The results indicated that all cases (100%) can be classified using this method. Such promising empirical evidence provide a strong basis for future clinical intervention studies on patients. The key changes are:

“To test the feasibility of the proposed system, 40 adults with non-specific chronic LBP were assessed on their movement preference (i.e. movement directions that can relieve pain or are pain-free) through the DMA Clinical Pilates method.” (lines 17-18)

“There exists a psychosocial approach to classify case complexity [6, 7] but patients may be bearing pain during exercise treatment because the psychosocial approach does not emphasize the physical limitation of the body.” (lines 42-44)

“This DMA Clinical Pilates approach is theoretically appealing because it allows patients to exercise comfortably without having to bear the pain.” (lines 53-54)

“To improve the clinical classification of case complexity in patients with LBP, the DMA Clinical Pilates method is potentially useful because this approach is objective and can take into account individual differences [10].” (lines 83-85)

 

“To test the feasibility of the proposed system, the method would be applied to classify 40 non-specific chronic LBP cases.” (lines 93-94)

 

“The theoretical consideration and assessment procedures of the proposed DMA Clinical Pilates case complexity classification system would be described. A case series approach was carried out to illustrate the feasibility of the proposed system in classifying non-specific chronic LBP.” (lines 97-100)

-Response: To substantial your point on the importance of conducting an intervention study, we have strengthened our Discussion in the revised manuscript. We clearly indicated that the current paper only detailed the theoretical considerations and assessment procedures of the DMA Clinical Pilates classification system but cannot inform whether patients undergoing this classification method will have better therapeutic outcomes. To address this additional research question, a randomized controlled trial is necessary in the future to compare patients whose clinical intervention have been informed by the proposed classification system versus those who have not.

Key changes in the manuscript:

“Future clinical intervention studies are needed to confirm if this classification system can enhance therapeutic outcomes in patients.” (lines 27-28)

“It should be noted that the current study only described the theoretical considerations and assessment procedures of the DMA Clinical Pilates classification system. Based on the presented information, we cannot inform whether patients undergoing this classification system will have better therapeutic outcomes. To address this research question, a randomized controlled trial is necessary in the future to compare patients whose clinical intervention have been informed by the proposed classification system verse those who have not.” (lines 272-278)

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

thank you for the answers and the changes made, which make the notable limitations of the work more explicit. I believe I have clearly expressed my point of view on the work and, since the key issues have been mentioned but not resolved (not due to your lack but because they cannot be resolved in a few days) I cannot change my opinion. Additionally, i would point out that saying that "Using the proposed system, all 40 (100%) LBP cases were successfully classified" (Abstract) is a strange statement. Taking the concept to the extreme (just to make it clearer), don't you think it would be possible to "successfully classify" patients also based on gender, height range or hair color? I use this hyperbole only to underline that it is not the grouping itself that brings an improvement, but the practical benefits that derive from it (if any). At the moment, the work, as far as I'm concerned, is of no usefulness both scientifically and clinically and needs to be rethought. Until that happens, I'm afraid I won't be able to change my opinion.