Title: The effects of videogames therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study.

Transcription

1 Author s response to reviews Title: The effects of videogames therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study. Authors: sofia straudi (s.straudi@ospfe.it) Giacomo Severini (giacomo.severini@ucd.ie) Amira Sabbagh Charabati (amira.s.charabati@gmail.com) Claudia Pavarelli (c.pavarelli@ospfe.it) Giulia Gamberini (giulia.gamberini5@gmail.com) Anna Scotti (a.scotti@ospfe.it) Nino Basaglia (n.basaglia@ospfe.it) Version: 1 Date: 31 Mar 2017 Author s response to reviews: Ferrara, March 31st 2017 Dear BMC Neurology Editors: We hereby resubmit our article entitled The effects of video game therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study. We thank the reviewers for their constructive and relevant comments that helped us to improve our manuscript. We rewrite the entire document (we highlighted the new section) that was successively edited by an English native speaker as requested. As follow, we reported our comments to the reviewers concerns: Ksenia Ustinova (Reviewer 1): The manuscript describes effects of videogames on balance and attention in chronic patients with ambulatory traumatic brain injury. This topic seems to be interesting and important to

2 medical/biological researchers, and professionals working in the area of neurological rehabilitation. The study is relatively well designed; the manuscript provides a solid structure for description of findings, and reports interesting results. This is strength of the manuscript. However, what I see as a major weakness is a serious lack of details that prevents a potential reader from seeing the significance of research findings, and a potential for further implementation of the results into practice. I recommend rewriting the manuscript and addressing the major and minor issues, listed below in the order they appear in the text. *Numbering of page lines is messed up with double numbers and there are no page numbers. I used citation from the text for reference. Abstract: 1. Chronic traumatic brain injury survivors does not seem to be appropriate definition form a stand point of people first language. You can say Individuals or Patients with traumatic brain injury We modify text accordingly. 2. In methods it is unclear what measures were used to assess attention. Please clarify. We specify that selective attention evaluation was made through the GonoGo task. 3. In conclusion, you cannot say Is can be hypothesized that these gains are due to the motivation harnessed by the virtual reality scenario. if you did not measure/evaluate motivation. Did you? There is typo at the beginning of the sentence. No, unfortunately we don t monitor motivation during this trial. The conclusion that people who receive VR are more engaged is only speculative and not related to our findings. We removed the sentence. Introduction: 4. Until now, balance rehabilitation in TBI has been poorly explored with limited evidence of its efficacy I would disagree with this statement as well as many other authors published on this topic. Please provide a short summary of what was done in this area of research, and what was not investigated yet. We included a brief summary of balance rehabilitation in TBI referring to both conventional or more experimental modalities. 5. We hypothesized that the video games therapy would improve balance, attention and subsequently motor recovery via a top-down approach. Please clarify what is top-down approach.

3 In this section, we included more text and references explaining why VGT compared to BPT would improve cognition and subsequently motor learning through a top-down approach. Materials and Methods: 6. This is an exploratory, unpowered, randomized, controlled study Please explain what is unpowered, randomized, controlled study means and why it is unpowered. Unpowered because this is a small convenience sample of patients. We used the UBS data prepost to calculate the sample size required to have a study with alfa 5% and beta 80%. We included in results section a small sample size calculation. We removed the sentence unpowered from the sentence above because it might sound redundant with exploratory and not easy understandable. 7. The x-y position of the Center of Pressure (COP, that is the projection of the Center of Mass on the support base) Someone can disagree that COP is projection of COM, many studies showed that those two parameters, are very close, but different. I recommend removing the text in parenthesis, except abbreviation COP. We amended. 8. There is not much information about the contents of VGT versus BPT therapies that makes the outcomes effects very questionable. Please describe in details: a. What types of movements/postural tasks patients performed in each of group? VGT: side stepping, lateral weight shifting, jumping, lateral, forward and backward walking, squats, goals reached by arms BPT: Balance/rebalancing, postural stability and weight shifting exercises b. Were these movements/tasks performed in block or were randomized? Movements were done in block. c. How much time patients spent for task performance itself and for the rest or between trials interval? VGT: 2-5 minutes/each game BPT: 2 minute/each exercise Rest if it was necessary.

4 d. How a level of game/task difficulty was defined at the beginning, and whether any progression was applied? VGT: During the first session, games and tasks were selected according to the patients characteristics, functional level and desires. The progression were made over time from the entry level to a more difficult one based on patients improvements. BPT: 3 progression levels. e. What types of feedback they received in each group? VGT: visual feedback, augmented feedback (knowledge of results and knowledge of performance), auditory and tactile feedback (PT) BPT: visual feedback, auditory and tactile feedback (PT), augmented feedback (knowledge of performance). f. How similar these tasks were to the tests used for assessment of balance and cognitive abilities? PBT trains more static balance tasks compared to VGT where dynamic tasks were trained. Looking at outcome measures: UBS assess both static and dynamic balance abilities, while CBM explore complex balance behaviours. Both UBS (La Porta 2011) and CB&M (Inness 2011) were found to be less susceptible to a ceiling effect than the commonly used balance scale such as Berg balance Scale. 9. Subjects were enrolled from the inpatient and outpatient rehabilitation clinics of Ferrara University Hospital Did they receive concurrent therapies, especially subjects from inpatient clinics? And if yes, what types of therapy they received? How those therapies might complement the effects of VGT or BPT? It needs to described in the methods section. Most of the sample (15 patients) was discharged at home and they were not doing physiotherapy or other interventions; 6 patients (1 dropped out) were receiving an inpatient multidisciplinary therapy even those they were in a chronic stage (see table 1). When we enrolled a patient from the inpatient, the balance training was performed only by the research team, whereas during the other rehabilitation time, other domains were trained (arms, ADLs, cognitive functions except for attention). Probably multidisciplinary rehabilitation can have boosted motor improvement, however no between-group baseline differences were highlighted respect on the rehabilitative setting. We decided to enroll patients both from home and inpatients because of the preliminary nature of the study and the complexity in chronic TBI recruitment.

5 We modify method section accordingly. Results: 10. We enrolled 21 ambulatory chronic traumatic brain injury patients Why the enrollment was limited by 21 subjects only, not many for randomized comparisons? We concluded the enrollment after only 21 patients because the enrollment rate was significantly lower respect to our expectations. However, some promising findings might be distinguished even in this exploratory study that can stimulate further investigations on the role of video games therapy in chronic TBI. Between-group differences were highlighted for UBS and TUG, however the superiority of VGT on BPT cannot be stated after this study. 11. Why recruitment stopped after 21 subjects were enrolled? Was it a convenience sample? It was stopped for the low recruitment rate. Our hospital deliver every year multidisciplinary rehabilitation for hundred of severe and moderate TBI. However, in a chronic phase, most of them was still very impaired or were not able to receive the balance therapy for organization reasons. Discussion: 12. Possible mechanisms of postural improvements after VGT are described relatively well. However, how VGT can improve selective attention is still unclear. The fact that This is consistent with previous works that highlighted how video game feedbacks are capable of improving visual selective attention in habitual players [33]. is not sufficient explanation. Please discuss all potential mechanisms underlying improvements in selective attention after playing video games. We included in the discussion a new paragraph about video games and attention. General: 13. There are lots of typos, missed punctuations, inconsistency in using lower versus upper case letters, and inappropriate use of verb tenses. Several examples are provided below, but this is only a very small portion of all typos found in the text. Authors should do more careful proofreading prior to submitting manuscript for review. a. Is can be hypothesized that Do you mean it? b. Subjects were enrolled from the inpatient and outpatient rehabilitation clinics of Ferrara University Hospital Inclusion criteria were: Is it one sentence or two?

6 c. GoNogo task subheading is followed by The Go-NoGo which one is correct? d. the Center of Mass on the support base) of the subjects will be calculated from forces and momenta measured by the force platform. These parameters will be or were calculated? By using the word momenta you mean momentum? Thanks for your time and efforts, we clean the text from typo errors and we submitted the entire work for proof-editing at the American Manuscript Editors service. 14. The manuscript must be proof-read by a native English speaker. See above. Karen McCulloch (Reviewer 2): This paper would benefit from editing by a native English speaker as there are numerous grammar and spelling errors throughout. We did proof-editing with the American Manuscript Editors. The use of the video game system for intervention shows the potential for use in the chronic population. Encourage mention of the selective attention measure in the abstract since results are cited there. We amended. Please clarify if the subjects in this study were undergoing any other therapy at the time, I assume not given the chronicity of injury, but clarify that. Most of the sample (15 patients) was discharged at home and they were not doing other physiotherapy or other interventions; 6 patients (1 dropped out) were receiving an inpatient multidisciplinary therapy even those they were in a chronic stage (see table 1). When we enrolled a patient from the inpatient, the balance training was performed only by the research team, whereas during the other rehabilitation time, other domains were trained (arms, ADLs, cognitive functions except for attention). Probably multidisciplinary rehabilitation can have boosted motor improvement, however no between-group baseline differences were highlighted respect on the rehabilitative setting. We decided to enroll patients both from home and inpatients because of the preliminary nature of the study and the complexity in chronic TBI recruitment. We modify method section accordingly. There is no mention of the possible effects of group differences in the discussion - since the videogames group was less chronic, could that have influenced the results? If not, then explain why.

7 Thanks for your comment. Yes, probably the time since TBI might have influenced our findings (2y VGT vs 8y BPT). Individuals with an higher chronicity may have developed more compensatory strategies, being less susceptible to modification with the rehabilitative interventions. We included this consideration in the discussion. Were the two groups comparable in terms of motor abilities? It appears from the balance measures that were taken pre-intervention that there may be group differences so that the balance platform training group was higher functioning, therefore having less room to improve on the measures. This flaw in design needs to be assessed or at least addressed. Yes, at baseline BPT group was higher functioning respect to UBS, CBM and TUG (even if not statistically significant). BPT did not improve in TUG (even if their scores were significantly higher than healthy subjects) or in CBM that is a balance scale specifically designed for highfunctioning TBI survivors. How was the assignment to group done? Perhaps assignment should have been based on balance ability and not demographic factors. This is an exploratory study, we allocated to treatment groups via a block randomization approach without any stratification for demographic or balance level. The conclusions drawn about attention testing seem overstated. We modify conclusion accordingly. We hope that the paper meets the high standards of the Journal, and look forward to hearing from you at your earliest convenience. Yours truly, Sofia Straudi, MD, PhD Ferrara University Hospital