Activity monitoring of stroke patients by physiotherapist and caregivers in a hospital setting

Apoorva M. Shankaranarayana; Yakub Sameerkhan Pattan; Nikhil Hegde; Manikandan Natarajan; Aparna R. Pai; Raghavendra Nayak; John M. Solomon

doi:10.12688/f1000research.124675.1

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Research Article

Activity monitoring of stroke patients by physiotherapist and caregivers in a hospital setting

[version 1; peer review: 1 approved, 1 approved with reservations, 2 not approved]

Apoorva M. Shankaranarayana¹, Yakub Sameerkhan Pattan¹, Nikhil Hegde¹, [...] Manikandan Natarajan^1,2, Aparna R. Pai³, Raghavendra Nayak⁴, John M. Solomon ^1,2

Apoorva M. Shankaranarayana¹, Yakub Sameerkhan Pattan¹, [...] Nikhil Hegde¹, Manikandan Natarajan^1,2, Aparna R. Pai³, Raghavendra Nayak⁴, John M. Solomon ^1,2

PUBLISHED 27 Oct 2022

Author details Author details

¹ Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
² Centre for Comprehensive Stroke Rehabilitation and Research, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
³ Department of Neurology, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
⁴ Department of Neurosurgery, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India

Apoorva M. Shankaranarayana
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Writing – Original Draft Preparation

Yakub Sameerkhan Pattan
Roles: Data Curation, Formal Analysis, Methodology

Nikhil Hegde
Roles: Data Curation, Formal Analysis, Methodology

Manikandan Natarajan
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Writing – Original Draft Preparation

Aparna R. Pai
Roles: Methodology, Resources, Writing – Review & Editing

Raghavendra Nayak
Roles: Methodology, Resources, Writing – Review & Editing

John M. Solomon
Roles: Conceptualization, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Background: Activity monitoring is a necessary technique to ensure stroke survivors’ activity levels in the hospital are within optimal levels as this is important for enhanced motor recovery. However, this could be time-consuming for healthcare professionals like physiotherapists. Activity monitoring by caregivers could be an alternate option. Therefore, our aim was to compare the activity monitoring of stroke survivors by caregivers and physiotherapists in a hospital setting.
Methods: An observation study was carried out in the neuroscience ward in a tertiary care hospital among 17 stroke survivors. Physiotherapist and caregivers were instructed to use an activity log chart that was developed during previous research conducted by the same authors for observing the activities performed by the patients every 15 minutes from 8 AM to 5 PM. Data collected were analysed using Stata 15. Kappa statistics were carried out to determine the agreement of the observations between the two raters.
Results: A total of 10 male and seven female caregivers of stroke survivors with a mean age of 40.11 ± 9.2 years participated in the study. A total of 272 observations of caregivers were in agreement with that of the physiotherapist. Inter-rater Kappa statistics showed 60% agreement between the physiotherapist and the caregivers, while the multi-rater Kappa for different time points did not show agreement (Kappa value <0.1).
Conclusions: There was moderate agreement between the physiotherapist and caregiver for activity monitoring of stroke survivors. This suggests behavioural mapping by caregivers may be a potential alternative solution in healthcare settings.

Keywords

Behavioural mapping, activity monitoring, stroke, hospitals, caregivers

Corresponding author: John M. Solomon

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Shankaranarayana AM et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Shankaranarayana AM, Pattan YS, Hegde N et al. Activity monitoring of stroke patients by physiotherapist and caregivers in a hospital setting [version 1; peer review: 1 approved, 1 approved with reservations, 2 not approved]. F1000Research 2022, 11:1227 (https://doi.org/10.12688/f1000research.124675.1) First published: 27 Oct 2022, 11:1227 (https://doi.org/10.12688/f1000research.124675.1) Latest published: 10 Nov 2023, 11:1227 (https://doi.org/10.12688/f1000research.124675.2)

Introduction

Stroke is one of the leading causes of death and disability worldwide.¹ The American Heart Association has predicted that 2.58 million people will have suffered a stroke by 2047 in Europe alone.² Functional impairment following acute illnesses, such as stroke, frequently has negative consequences, including sensory, motor, psychosocial, cognitive, and sexual dysfunctions.³^–⁶ Due to these impairments, stroke survivors have significantly reduced activity levels from an early phase.⁷

The importance of being active from an early phase is well-established in stroke survivors. The evidence for functional recovery is rapid in the acute phase and depends on several factors including the amount of activity that is done by the patient.⁸^,⁹ Hence, it is vital for stroke survivors to be active from an early phase. However, patients undergoing inpatient rehabilitation after stroke have limited opportunities to be active.¹⁰^,¹¹ As a result, sedentary behaviour during the hospital stay could limit the potential for optimal stroke recovery. Studies suggest that stroke survivors are sedentary in hospital settings and are described as ‘inactive and alone’.⁹ This is concerning because of the strong association between higher levels of inactivity and a decreased rate of functional recovery.¹² For this reason, special interest has been placed to explore the amount of activities in stroke patients during the early phase.¹³

Behavioural mapping is a well-known observational method that can be used for recording and observing various behaviours.¹⁴ It allows researchers and clinicians the opportunity to collect, analyse and represent information in resourceful ways, which help to determine how one's environment may influence their behaviour.¹⁵ It is an effective tool to represent behavioural patterns in any location.¹⁶^,¹⁷ Behavioural mapping has also been used for assessing patients' behaviour in hospital settings, including monitoring their physical, cognitive and social activities.¹⁸^–²⁰

By using this method to measure stroke survivors’ activity levels in hospital wards can help determine their activity and sedentary behaviour. Existing studies show that behavioural mapping for activity monitoring is mostly carried out by professionals or researchers, including physiotherapists, and is usually done either for one or multiple days.¹⁸^,¹⁹^,²¹^–²³ However, this method poses a challenge for the healthcare workers as it can be time-consuming due to a longer evaluation period. Hence, it may require multiple people to monitor the activities of the patient, making the method less feasible.

Activity monitoring by caregivers of the patients may be an alternative solution. Caregivers are known to be with the patient for a large amount of time during their hospital stay.²⁴ However, the accuracy of measurement by caregivers compared to monitoring by rehabilitation professionals need to be ascertained. Therefore, the study aimed to determine the interrater agreement between the activity monitoring of stroke survivors carried out by the caregivers and physiotherapist in an acute hospital setting.

Methods

Ethics

This study was a part of a larger ongoing study that aims to enhance the activity levels of stroke survivors and was approved by the Institutional Ethics Committee, Kasturba Medical College and Kasturba Hospital, Manipal (IEC 438/2019) on 16^th July, 2019. This study was conducted prior to the commencement of the main study and included a different population of participants. The study was conducted in the neuroscience ward of Kasturba Hospital, Manipal in Southern India.

Participants

Eligibility criteria

All the stroke patients admitted to the ward were screened for the eligibility criteria from July 2020 to November 2020. As this was a pilot study, we conducted a time-bound design. We included caregivers of stroke patients affected with the supra-tentorial lesions, aged between 18 and 80 years, medically stable with no other comorbidities and who could functionally communicate. We excluded caregivers of patients who underwent surgery and with other impairments like fractures, musculoskeletal, cardiovascular, neurological and other chronic diseases that could affect their activity levels. In addition, we only included primary caregivers who are with the patient for most time during the day in the ward. Further, we included caregivers without any psychological/psychiatric disorders and who could functionally communicate.

Outcome

The behavioural mapping was carried out using an activity log chart that has been developed to monitor the activities of the stroke patient during their hospital stay. It has components of physical, cognitive and social activities that stroke patients perform in a hospital. All the activities in the activity log chart were finalized after conducting a thorough literature search and observations of activities performed by the stroke patients in the hospital for nine hours per day for a duration of one week. The log chart has activities written in English and Kannada (regional language) along with the image depicting the activity being performed. This was to ensure that the caregivers comprehend the log chart, irrespective of their education level. The activity log chart can be found as Underlying data.³¹ Further, the log chart was sent to 15 experts for validation and was tested on 20 stroke patients prior to the commencement of this study (unpublished work, Shankaranarayana AM, Natarajan M, Solomon JM). The copyright for the log chart has been applied with the Government of India.

Procedure

All stroke patients admitted in the neuroscience ward were screened for the criteria. Eligible patients and their caregivers were explained about the study, and written informed consent was obtained from both patients and caregivers. An intern in physiotherapy was recruited and informed consent from the physiotherapist was taken. The caregivers and the physiotherapist were explained about the procedure of monitoring the patients along with the usage of the activity log chart. All the instructions to record the activities were provided one day prior to the day of observation and the principal investigator clarified any queries regarding activities to be monitored. In addition, the caregivers were also trained to use the activity log chart by simulating examples.

The activities in the chart were grouped into physical, social and cognitive activity, and both the raters (caregiver and the physiotherapist) were asked to mark a tick (✓) against the corresponding activity that the patient was doing at a particular time slot. At any time, if the patient was doing two or more activities at the same time (example: eating and reading, walking and talking), the raters were asked to mark both the activities. The observations were carried out every 15 minutes by both the caregiver and physiotherapist for a single day. This allows a total possibility of 37 observations per patient by each rater. The principal investigator (AMS) provided the chart before 8 AM on the day of observation and collected it back at 5 PM after the caregiver completed all the observations. Both the caregiver and physiotherapist were instructed and monitored by the principal investigator to not discuss or see the other person’s chart to prevent contamination of results. The caregivers were informed to monitor the patients’ activities as much as they possibly could during that time period. A research assistant was consigned to conduct periodic monitoring with the caregivers about their activity monitoring.

Statistical analysis

Descriptive statistics were used to summarize the demographic characteristics of patients and caregivers. Percentage agreement for monitoring between the caregiver and the physiotherapist was calculated for overall activities, each domain and each activity. Analysis was carried out using Stata 15 (RRID:SCR_012763) (free alternative, Rstudio). Agreement between the two raters domain wise was assessed using Kappa statistics. Multi-rater kappa was used to assess the agreement across the different time points. Kappa values of ≤ 0 as indicating no agreement and 0.01–0.20 as none to slight, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as good agreement.²⁵

Results

A total of 60 stroke participants were assessed for eligibility and 17 were recruited for this study. The main reasons for excluding were patients who underwent surgery (n=26), patients with recurrent stroke (n=12) and those who could not comprehend (n=5). The demographic characteristics of the stroke survivors and caregivers who participated in the study are given in Table 1 and Table 2, respectively.³¹

Table 1. Demographic characteristics of the stroke survivors in the study (n=17).

Characteristics	Value
Age in years (Mean ± SD)	53.35 ± 16.4
Sex
Male:	10
Female	07
NIHSS score
Mild:	11
Moderate:	04
Moderate to severe:	02
Post stroke duration in days (Mean ± SD)	3.47 ± 1.32
Type of stroke
Ischaemic:	11
Haemorrhagic:	06
Side of stroke
Left:	12
Right:	05

Table 2. Socio-educational details of the caregivers who participated in the study (n=17).

Characteristics	Frequency (number of participants)
Relation to the patient
Spouse:	08
Children/Grandchildren:	06
Daughter-in-law:	01
Sibling:	02
Education
Nil:	01
<High school:	04
High school:	08
Graduate:	04
Occupation
Homemaker:	05
Farmer:	03
Employed:	05
Healthcare worker:	01
Own business/freelancer:	03
Basic knowledge* about stroke	06
Previous experience as a caregiver in a hospital	05

* Fundamental causes, treatments and prognosis of the stroke.

A total of 17 caregivers of the stroke survivors, of which 10 were male and seven female participated in the study with the mean (SD) age of 40.11 ± 9.2 years. The socio-educational details of the caregivers who participated in the study are given in Table 2.

The behavioural mapping carried out showed the following observations. Out of the possible 629 observations (37 observations/participant), the physiotherapist marked 535 (85%), while caregivers marked 424 (67.5%). A total of 272 out of 424 (64.2%) caregiver observations had an agreement with the physiotherapist observations.

Agreement between caregivers and physiotherapist varied significantly for different activities as it ranged from 0% (lowest) for bathing, dressing and 100% (highest) for grooming. The percentage agreement for different activities monitored by caregivers and physiotherapist are shown in Figure 1. Further, the agreement of activities under physical, cognitive and social domains were 42, 38 and 43%, respectively.

Figure 1. Percentage agreement for different activities.

Inter-rater agreement between the caregiver and the physiotherapist for the various activities showed a Cohen’s Kappa of 0.61 with 95% CI (0.55, 0.66) and p value <0.001, while the multi-rater Kappa for different time points in a day showed <0.1 agreement.

Discussion

The aim of this study was to compare the observations made by physiotherapist and caregivers to capture the possibility of the caregivers in monitoring the patients’ activities in acute care settings. Our results showed that the agreement between both the observations was 64.2%, implying that caregivers could not monitor the activity of patients as accurately as the physiotherapist. However, the discrepancy in the observations could be due to many reasons. First, the subjectivity of the behavioural mapping by itself could have led to the variability in observations.²⁶ Second, though the instructions were given to observe every 15 minutes, the time of observation could have varied by seconds between the physiotherapist and the caregivers, which is enough to change the activity. For example, in the initial seconds of 8 AM (8:00:00) the patient may have been sitting, but by the end of 8 AM (8:00:45), he may be standing and talking. Hence, the patient could have switched their activity between those two observations, leading to variability. Another reason may be due to the variability that could have occurred in situations while the patient was performing more than one activity simultaneously. Although the caregivers were asked to mark all the activities in such situations, it was noted that quite a few times the caregiver had only marked a single activity whilst the physiotherapist had marked dual activities. For instance, a patient walking while talking over the phone was marked for walking alone by the caregiver, while the physiotherapist marked both walking and talking on the phone.

Though the caregivers are with patients most of the time in the hospital, they may move out of the ward for various requirements related to the patient and for other personal reasons. These reasons could explain the reduced percentage of observations by caregivers compared to the physiotherapist. These reasons were supported by a recent study, which states that a family caregiver has high intensity role in the hospital as they have to multitask both physically and mentally.²⁷ These roles make it challenging for them to tend to additional work besides situations associated with illness and dependency of the patient during the hospital stay.²⁸ Additionally, evidence shows that caregivers of acute diseases like stroke have more compounded situations due to the sudden change in adaptation required compared to chronic diseases.²⁹ Another reason could be the change in caregiver of the patient during the observation day. The replaced caregiver would have not received the entire instructions from the previous caregiver leading to loss of vital information regarding the observations. Hence, the new caregiver might not have understood the procedure adequately and did not record the activities diligently. Further, although we used pictures along with words to depict the activities in the log chart, we noticed that many caregivers had not marked the activities for all the time slots. The comprehension level and differences in the education level could be the reason for this. All caregivers had some level of formal education except for one.

A total of 12 caregivers in our study had no previous hospital experience. Since the majority of the caregivers lacked experience in managing a hospital, anxiety and unfamiliarity of the situations in the hospital could have been the reason for the overall reduced activity loggings. This was supported by an earlier study that showed that new caregivers have a higher level of burden and anxiety in the hospital,²⁴ which might have influenced the observations significantly.

We noticed that caregivers could log some additional activities that the physiotherapist could not. Bathing and dressing were a few such activities that the physiotherapist had not marked. Due to the separate bathing area where the caregivers accompanied the patients sometimes to assist, they could log the activity. However, the physiotherapist on such occasions, could not differentiate and had either not logged anything or marked it as toileting. Whereas, overall, the caregiver had logged both toileting and bathing appropriate to the time slots. In this study, both the physiotherapist and the caregiver did not complete all observations. In the hospitals, for various tests, patients are taken to different test/diagnostic rooms,³⁰ during which, it would be difficult to monitor patients for their activities. This could be one of the primary reasons for lesser observations made by both physiotherapist and caregivers.

The Kappa statistics showed 60% agreement between the physiotherapist and the caregiver. Even though this is not ideal, there is moderate level agreement seen. There may be a potential for enhancing the agreement levels if all the above-mentioned problems are addressed. However, we had a low agreement across the time points on multi-rater kappa. This could be due to the low sample for each time point across all the patients.

To our knowledge, this is the first study that compared behavioural mapping between the physiotherapist and the caregivers for the activities performed by stroke patients. The limitation of this study is that it had a low sample size, as this was a phase in a bigger study. We did not do location mapping during the behavioural mapping as it was a fixed location. All the patients recruited were from the same general ward. In addition, as the monitoring was new and unfamiliar to the caregivers, we did not impose the extra detail of location and people present, which are usually carried out during behavioural mapping. Second, the observations in the study were done only on a single day. Third, behavioural mapping is a subjective measure of assessment. However, it is the best available method for assessing or recording an individual’s behaviour.

Although activity monitoring by caregivers was in moderate agreement with the observations made by physiotherapist, it is important to note that some of the toiletry activities were monitored only by the caregivers. Further, the agreement level may have scope for improvement considering that some of the above issues are modifiable. Thus, there is a potential for caregivers to perform behavioural mapping of stroke. This paves way for a feasible method of behavioural mapping in healthcare settings. Future studies are directed towards the larger sample and longer periods of activity monitoring.

Data availability

Underlying data

Figshare: F1000 data final. https://doi.org/10.6084/m9.figshare.21076363.³¹

This project contains the following underlying data:

- Activity Log Chart.pdf
- Data repository.xlsx (participant spreadsheet data)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

1. Johnson W, Onuma O, Owolabi M, et al.: Stroke: a global response is needed. Bull. World Health Organ. 2016; 94: 634–634A. PubMed Abstract | Publisher Full Text
2. Wafa HA, Wolfe CDA, Emmett E, et al.: Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years. Stroke. 2020; 51: 2418–2427. PubMed Abstract | Publisher Full Text
3. Taylor-Rowan M, Cuthbertson G, Keir R, et al.: The prevalence of frailty among acute stroke patients, and evaluation of method of assessment. Clin. Rehabil. 2019; 33: 1688–1696. PubMed Abstract | Publisher Full Text
4. Dorsch S, Ada L, Canning CG: Lower Limb Strength Is Significantly Impaired in All Muscle Groups in Ambulatory People With Chronic Stroke: A Cross-Sectional Study. Arch. Phys. Med. Rehabil. 2016; 97: 522–527. PubMed Abstract | Publisher Full Text
5. Greenham M, Gordon AL, Cooper A, et al.: Social functioning following pediatric stroke: contribution of neurobehavioral impairment. Dev. Neuropsychol. 2018; 43: 312–328. PubMed Abstract | Publisher Full Text
6. Middaugh SJ, Whitehead WE, Burgio KL, et al.: Biofeedback in treatment of urinary incontinence in stroke patients. Biofeedback Self Regul. 1989; 14: 3–19. PubMed Abstract | Publisher Full Text
7. Field MJ, Gebruers N, Shanmuga Sundaram T, et al.: Physical Activity after Stroke: A Systematic Review and Meta-Analysis. ISRN Stroke. 2013; 2013: 1–13. Publisher Full Text
8. de Leciñana MA , Gutiéérrez-Fernández M, Romano M, et al.: Strategies to Improve Recovery in Acute Ischemic Stroke Patients: Iberoamerican Stroke Group Consensus. Int. J. Stroke. 2014; 9: 503–513. PubMed Abstract | Publisher Full Text
9. Bernhardt J, Dewey H, Thrift A, et al.: Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke. 2004; 35: 1005–1009. Publisher Full Text
10. Kunkel D, Fitton C, Burnett M, et al.: Physical inactivity post-stroke: a 3-year longitudinal study. Disabil. Rehabil. 2015; 37: 304–310. PubMed Abstract | Publisher Full Text
11. Ezeugwu VE, Manns PJ: Sleep Duration, Sedentary Behavior, Physical Activity, and Quality of Life after Inpatient Stroke Rehabilitation. J. Stroke Cerebrovasc. Dis. 2017; 26: 2004–2012. PubMed Abstract | Publisher Full Text
12. Askim T, Bernhardt J, Salvesen Ø, et al.: Physical Activity Early after Stroke and Its Association to Functional Outcome 3 Months Later. J. Stroke Cerebrovasc. Dis. 2014; 23: e305–e312. PubMed Abstract | Publisher Full Text
13. Alawieh A, Zhao J, Feng W: Factors affecting post-stroke motor recovery: Implications on neurotherapy after brain injury. Behav. Brain Res. 2018; 340: 94–101. PubMed Abstract | Publisher Full Text
14. Ng CF:Behavioral Mapping and Tracking. Research Methods for Environmental Psychology. John Wiley & Sons, Ltd;pp. 29–51. Publisher Full Text
15. Cosco NG, Moore RC, Islam MZ: Behavior Mapping: A Method for Linking Preschool Physical Activity and Outdoor Design. Med. Sci. Sports Exerc. 2010; 42: 513–519. Publisher Full Text
16. Cox A, Loebach J, Little S: Understanding the Nature Play Milieu: Using Behavior Mapping to Investigate Children’s Activities in Outdoor Play Spaces. Child. Youth Environ. 2018; 28: 232–261.
17. Alam BM: Application of Geographic Information Systems. BoD – Books on Demand;2012. Publisher Full Text
18. Janssen H, Ada L, Bernhardt J, et al.: An enriched environment increases activity in stroke patients undergoing rehabilitation in a mixed rehabilitation unit: a pilot non-randomized controlled trial. Disabil. Rehabil. 2014; 36: 255–262. PubMed Abstract | Publisher Full Text
19. Rosbergen IC, Grimley RS, Hayward KS, et al.: Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before–after pilot study. Clin. Rehabil. 2017; 31: 1516–1528. PubMed Abstract | Publisher Full Text
20. Valkenet K, Bor P, van Delft L , et al.: Measuring physical activity levels in hospitalized patients: a comparison between behavioural mapping and data from an accelerometer. Clin. Rehabil. 2019; 33: 1233–1240. PubMed Abstract | Publisher Full Text
21. Mackey F, Ada L, Heard R, et al.: Stroke rehabilitation: Are highly structured units more conducive to physical activity than less structured units? Arch. Phys. Med. Rehabil. 1996; 77: 1066–1070. PubMed Abstract | Publisher Full Text
22. Prakash V, Shah MA, Hariohm K: Family’s presence associated with increased physical activity in patients with acute stroke: an observational study. Braz. J. Phys. Ther. 2016; 20: 306–311. PubMed Abstract | Publisher Full Text
23. Anåker A, von Koch L , Sjöstrand C, et al.: The physical environment and patients’ activities and care: A comparative case study at three newly built stroke units. J. Adv. Nurs. 2018; 74: 1919–1931. PubMed Abstract | Publisher Full Text
24. Pérez-Cruz M, Parra-Anguita L, López-Martínez C, et al.: Burden and Anxiety in Family Caregivers in the Hospital That Debut in Caregiving. IJERPH. 2019; 16: 3977. PubMed Abstract | Publisher Full Text
25. Sim J, Wright CC: The Kappa Statistic in Reliability Studies: Use, Interpretation, and Sample Size Requirements. Phys. Ther. 2005; 85: 257–268. PubMed Abstract | Publisher Full Text
26. Anderson WH, Ha JW, Couper DJ, et al.: Variability in objective and subjective measures affects baseline values in studies of patients with COPD. PLoS One. 2017; 12: e0184606. PubMed Abstract | Publisher Full Text
27. Hsu T, Nathwani N, Loscalzo M, et al.: Understanding Caregiver Quality of Life in Caregivers of Hospitalized Older Adults With Cancer. J. Am. Geriatr. Soc. 2019; 67: 978–986. PubMed Abstract | Publisher Full Text
28. Plank A, Mazzoni V, Cavada L: Becoming a caregiver: new family carers’ experience during the transition from hospital to home: New family carers’ experience. J. Clin. Nurs. 2012; 21: 2072–2082. PubMed Abstract | Publisher Full Text
29. Moral-Fernández L, Frías-Osuna A, Moreno-Cámara S, et al.: The start of caring for an elderly dependent family member: a qualitative metasynthesis. BMC Geriatr. 2018; 18: 228. PubMed Abstract | Publisher Full Text
30. Junker R, Schlebusch H, Luppa PB: Point-of-Care Testing in Hospitals and Primary Care. Deutsches Aerzteblatt Online. 2010. Epub ahead of print 20 August. Publisher Full Text
31. Shankaranarayana AM:F1000 data final. figshare. [Dataset]. 2022. Publisher Full Text

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 27 Oct 2022

Author details Author details

Apoorva M. Shankaranarayana
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Writing – Original Draft Preparation

Yakub Sameerkhan Pattan
Roles: Data Curation, Formal Analysis, Methodology

Nikhil Hegde
Roles: Data Curation, Formal Analysis, Methodology

Manikandan Natarajan
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Writing – Original Draft Preparation

Aparna R. Pai
Roles: Methodology, Resources, Writing – Review & Editing

Raghavendra Nayak
Roles: Methodology, Resources, Writing – Review & Editing

John M. Solomon
Roles: Conceptualization, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

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Revised

Published: 10 Nov 2023, 11:1227

https://doi.org/10.12688/f1000research.124675.2

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Published: 27 Oct 2022, 11:1227

https://doi.org/10.12688/f1000research.124675.1

© 2022 Shankaranarayana AM et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Shankaranarayana AM, Pattan YS, Hegde N et al. Activity monitoring of stroke patients by physiotherapist and caregivers in a hospital setting [version 1; peer review: 1 approved, 1 approved with reservations, 2 not approved]. F1000Research 2022, 11:1227 (https://doi.org/10.12688/f1000research.124675.1)

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Reviewer Report 12 Oct 2023

Ketaki Inamdar, Virginia Commonwealth University, Richmond, Virginia, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.136897.r208335

It was a pleasure to read the paper. The study's results tackle a persistent challenge in literature, namely the monitoring of physical and other activities in clinical populations, offering a novel solution. For this reason, I believe these findings should be considered for indexing. However, I would like to recommend significant modifications to enhance the scientific rigor of the study. The current results are presented too strongly given the design and sample size. I suggest toning down the findings, emphasizing the pilot and feasibility testing component of the study, and engaging in a critical discussion on how these results can inform the design of caregiver-monitored activity logs during early-phase stroke rehabilitation.

Title:

Consider adding "Pilot" to the title due to the sample size.

Abstract:
Well-written, minor suggestions:

Consider adding "early phase" before "hospital settings" to distinguish from outpatient rehabilitation.
Insert "across one day" before "every 15 minutes" for clarity.
Include brief demographics for physiotherapists as participants.

Introduction:
Paragraph 1:
Please incorporate stroke statistics specific to India to substantiate the study's relevance. Utilize percentages to illustrate the impact, particularly when stating that "stroke survivors have significantly reduced activity levels."

Define "early phase" at the outset to enhance the paper's readability.

Paragraph 2:

Expand on the benefits of increased activity during the acute phase of stroke recovery and delineate the factors that limit activity, especially in the post-acute phase.

Paragraph 3:

Briefly talk about the different tools used for behavioural mapping such as video recording, checklists, wearable devices etc., with a brief discussion on pros and cons for each method. Please justify why you selected checklist/log.

Methods:
Inclusion criteria:

“Functionally communicate” has been used twice in the paragraph.
Include the inclusion criteria for physiotherapists, specifying their level of expertise (e.g., trained neurophysiotherapists, novice clinicians, experienced clinicians) to provide context on their participation and qualifications in the study.

Outcome:

Elaborate on the process of developing the activity log, specifying whether the validation involved face validation or content validation, to enhance the clarity and rigor of the log development.
Specify whether the testing involving 20 stroke patients was related to assessing the practicality and usability of the log. This clarification will provide a better understanding of the purpose and focus of the testing phase.
Finally, explain why exercise was categorized separately from therapies in the activity log. Given that therapies often encompass exercise in the early phase, clarify the rationale for this distinction and consider discussing how this categorization may have contributed to any discrepancies observed between physiotherapists and caregivers.

Procedure:

Clarify whether the intern-to-patient ratio was 1:1 or if the intern monitored more than one patient on a particular day. Specify the procedure for patient monitoring when the intern had to take a break.
Indicate whether caregivers were provided with reminders or prompts every 15 minutes during the monitoring process.
Provide a rationale for selecting only one working day for agreement testing.

Statistical Analysis:

Due to the limited sample size in this study, it is important to provide a justification for the chosen sample size. Include information regarding whether a power analysis was conducted.
I believe the study lacks sufficient statistical power for utilizing multi-rater kappa, a concern that is indeed emphasized in the discussion. It might be worth considering excluding these specific findings.

Results:

Integrate relevant details about the physiotherapists into the tables or corresponding paragraphs within the Results section.
Organizing the kappa agreement according to the three domains of activities in Figure 1 would be beneficial. This would offer insights into the level of agreement within each domain, allowing for a comparison of agreement quality across the domains.

Discussion:
Overall, the authors effectively emphasize the feasibility of utilizing caregiver led activity logs and underscore how the design of the activity log can impact agreement. However, enhancing the discussion through a more critical comparison with existing studies would further bolster the strength of the argument.

Here are some suggestions for the discussion:

Draw parallels with the fundamental concepts of Ecological Momentary Assessment (EMA) and elaborate on how periodic reminders every 15 minutes could have impacted the reporting within this study.
Compare the role of caregiver burden and recall burden in subjective reporting studies conducted in similar and other clinical populations.
Address the learning curve associated with reporting multiple activities by caregivers. The limited reporting duration in this single-day study may not have allowed caregivers to fully grasp the intricacies of reporting various activities, especially if a change in caregivers occurred during the day.
A discussion on alternative activity tracking methods, such as wearable sensors, should have been included.
Include a discussion of the rationale behind selecting specific activities, particularly during the initial phase, and its influence on the reporting process. For instance, considering that physiotherapists were unable to access the bathroom area, consolidating toileting-related activities into a single category could ensure equal reporting opportunities for both physiotherapists and caregivers. Likewise, it is anticipated that patients would undergo clinical monitoring and testing early in their recovery phase. Future studies may consider incorporating this aspect into the activity log to mitigate discrepancies related to this particular activity.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Neurophysiotherapy, activity monitoring

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 10 Nov 2023

John M Solomon, Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, 576104, India

10 Nov 2023

Author Response
We, the authors, convey our sincere thanks to the reviewer for spending their valuable time reviewing our manuscript. We are pleased to know the suggestions/ modifications advised. The suggestions helped ... Continue reading
We, the authors, convey our sincere thanks to the reviewer for spending their valuable time reviewing our manuscript. We are pleased to know the suggestions/ modifications advised. The suggestions helped to enhance the quality of the manuscript. All the suggestions were incorporated/ addressed in the revised manuscript. Our response can be identified below in italics and bold.

Title: Consider adding "Pilot" to the title due to the sample size.

Thank you, we agree. We have made a request to the journal for a change in title.

Abstract: Well-written, minor suggestions:

•              Consider adding "early phase" before "hospital settings" to distinguish from outpatient rehabilitation.
•              Insert "across one day" before "every 15 minutes" for clarity
•              Include brief demographics for physiotherapists as participants.
The authors would like to thank the reviewer for the suggestion. The suggested changes have been incorporated into the abstract.

Introduction:

Paragraph 1: Please incorporate stroke statistics specific to India to substantiate the study's relevance. Utilize percentages to illustrate the impact, particularly when stating that "stroke survivors have significantly reduced activity levels."
•              Define "early phase" at the outset to enhance the paper's readability.
Paragraph 2: Expand on the benefits of increased activity during the acute phase of stroke recovery and delineate the factors that limit activity, especially in the post-acute phase.
Paragraph 3: Briefly talk about the different tools used for behavioural mapping such as video recording, checklists, wearable devices etc., with a brief discussion on pros and cons for each method. Please justify why you selected checklist/log.
Thank you for this suggestion. We have added the prevalence data from India and the percentage to the statement. This brings in more clarity to the given information.
Early phase has been defined as suggested. Thank you
We appreciate this suggestion to emphasize the importance of being active and the same has been added.
We agree that the details would give a better insight. We have added more information about the different tools used.

Methods:

Inclusion criteria:
“Functionally communicate” has been used twice in the paragraph.
Include the inclusion criteria for physiotherapists, specifying their level of expertise (e.g., trained neurophysiotherapists, novice clinicians, experienced clinicians) to provide context on their participation and qualifications in the study.
Thank you for the suggestion. We have used it twice for two different population. The first one refers to the eligibility in stroke survivors and the second mentioning refers to their caregivers.
We are obliged to rectify this. The same has been added in the methods section.

Outcome:

•              Elaborate on the process of developing the activity log, specifying whether the validation involved face validation or content validation, to enhance the clarity and rigor of the log development.
•              Specify whether the testing involving 20 stroke patients was related to assessing the practicality and usability of the log. This clarification will provide a better understanding of the purpose and focus of the testing phase.
•              Finally, explain why exercise was categorized separately from therapies in the activity log. Given that therapies often encompass exercise in the early phase, clarify the rationale for this distinction and consider discussing how this categorization may have contributed to any discrepancies observed between physiotherapists and caregivers.
The author would like to thank the reviewer for these suggestions. We have added content validation of the log chart to bring in more clarity and the objective of the testing.
We appreciate the suggestion and have added the same. However, in our opinion, these details would better suit in the manuscript pertaining to the development of the activity log chart.

Procedure:

•              Clarify whether the intern-to-patient ratio was 1:1 or if the intern monitored more than one patient on a particular day. Specify the procedure for patient monitoring when the intern had to take a break.
•              Indicate whether caregivers were provided with reminders or prompts every 15 minutes during the monitoring process.
•              Provide a rationale for selecting only one working day for agreement testing.
Thank you for the valuable suggestion. This will help give more details about the procedure. We have edited the same.
We have added the suggested information. Thank you.
We are obliged to rectify this. The same has been added.

Statistical Analysis:

•              Due to the limited sample size in this study, it is important to provide a justification for the chosen sample size. Include information regarding whether a power analysis was conducted.
•              I believe the study lacks sufficient statistical power for utilizing multi-rater kappa, a concern that is indeed emphasized in the discussion. It might be worth considering excluding these specific findings.
We agree with the reviewer. We did a power analysis and the same has been noted in the statistics and results part of the paper. We did not calculate the sample size as this was a pilot study.
We are obliged to rectify this and have removed the same from the manuscript.

Results:

•              Integrate relevant details about the physiotherapists into the tables or corresponding paragraphs within the Results section.
•              Organizing the kappa agreement according to the three domains of activities in Figure 1 would be beneficial. This would offer insights into the level of agreement within each domain, allowing for a comparison of agreement quality across the domains.
We are obliged to rectify this. The same has been added in the text of the results section.
Thank you for the suggestion. In our opinion, arranging the items according to the descending order brings in readability and clarity. However, the suggested information has already been added in the text section.

Discussion:

Overall, the authors effectively emphasize the feasibility of utilizing caregiver led activity logs and underscore how the design of the activity log can impact agreement. However, enhancing the discussion through a more critical comparison with existing studies would further bolster the strength of the argument.Here are some suggestions for the discussion:
•              Draw parallels with the fundamental concepts of Ecological Momentary Assessment (EMA) and elaborate on how periodic reminders every 15 minutes could have impacted the reporting within this study.
•              Compare the role of caregiver burden and recall burden in subjective reporting studies conducted in similar and other clinical populations.
•              Address the learning curve associated with reporting multiple activities by caregivers. The limited reporting duration in this single-day study may not have allowed caregivers to fully grasp the intricacies of reporting various activities, especially if a change in caregivers occurred during the day.
•              A discussion on alternative activity tracking methods, such as wearable sensors, should have been included.
•              Include a discussion of the rationale behind selecting specific activities, particularly during the initial phase, and its influence on the reporting process. For instance, considering that physiotherapists were unable to access the bathroom area, consolidating toileting-related activities into a single category could ensure equal reporting opportunities for both physiotherapists and caregivers. Likewise, it is anticipated that patients would undergo clinical monitoring and testing early in their recovery phase. Future studies may consider incorporating this aspect into the activity log to mitigate discrepancies related to this particular activity.
Thank you. We appreciate the suggestions put forth for our discussion.
This is a very good point to add. The authors appreciate the reviewer for the suggestion. We have added details of the same.
Thank you for the suggestion. The role of caregiver and the burden has already been discussed.
We agree that this would be an important finding to discuss. The same has been added.
Thank you. We agree to this. We have added the same in the discussion.
We appreciate the detailed suggestion. This is very insightful. We have added the same.
We, the authors, convey our sincere thanks to the reviewer for spending their valuable time reviewing our manuscript. We are pleased to know the suggestions/ modifications advised. The suggestions helped to enhance the quality of the manuscript. All the suggestions were incorporated/ addressed in the revised manuscript. Our response can be identified below in italics and bold.

Title: Consider adding "Pilot" to the title due to the sample size.

Thank you, we agree. We have made a request to the journal for a change in title.

Abstract: Well-written, minor suggestions:

•              Consider adding "early phase" before "hospital settings" to distinguish from outpatient rehabilitation.
•              Insert "across one day" before "every 15 minutes" for clarity
•              Include brief demographics for physiotherapists as participants.
The authors would like to thank the reviewer for the suggestion. The suggested changes have been incorporated into the abstract.

Introduction:

Paragraph 1: Please incorporate stroke statistics specific to India to substantiate the study's relevance. Utilize percentages to illustrate the impact, particularly when stating that "stroke survivors have significantly reduced activity levels."
•              Define "early phase" at the outset to enhance the paper's readability.
Paragraph 2: Expand on the benefits of increased activity during the acute phase of stroke recovery and delineate the factors that limit activity, especially in the post-acute phase.
Paragraph 3: Briefly talk about the different tools used for behavioural mapping such as video recording, checklists, wearable devices etc., with a brief discussion on pros and cons for each method. Please justify why you selected checklist/log.
Thank you for this suggestion. We have added the prevalence data from India and the percentage to the statement. This brings in more clarity to the given information.
Early phase has been defined as suggested. Thank you
We appreciate this suggestion to emphasize the importance of being active and the same has been added.
We agree that the details would give a better insight. We have added more information about the different tools used.

Methods:

Inclusion criteria:
“Functionally communicate” has been used twice in the paragraph.
Include the inclusion criteria for physiotherapists, specifying their level of expertise (e.g., trained neurophysiotherapists, novice clinicians, experienced clinicians) to provide context on their participation and qualifications in the study.
Thank you for the suggestion. We have used it twice for two different population. The first one refers to the eligibility in stroke survivors and the second mentioning refers to their caregivers.
We are obliged to rectify this. The same has been added in the methods section.

Outcome:

•              Elaborate on the process of developing the activity log, specifying whether the validation involved face validation or content validation, to enhance the clarity and rigor of the log development.
•              Specify whether the testing involving 20 stroke patients was related to assessing the practicality and usability of the log. This clarification will provide a better understanding of the purpose and focus of the testing phase.
•              Finally, explain why exercise was categorized separately from therapies in the activity log. Given that therapies often encompass exercise in the early phase, clarify the rationale for this distinction and consider discussing how this categorization may have contributed to any discrepancies observed between physiotherapists and caregivers.
The author would like to thank the reviewer for these suggestions. We have added content validation of the log chart to bring in more clarity and the objective of the testing.
We appreciate the suggestion and have added the same. However, in our opinion, these details would better suit in the manuscript pertaining to the development of the activity log chart.

Procedure:

•              Clarify whether the intern-to-patient ratio was 1:1 or if the intern monitored more than one patient on a particular day. Specify the procedure for patient monitoring when the intern had to take a break.
•              Indicate whether caregivers were provided with reminders or prompts every 15 minutes during the monitoring process.
•              Provide a rationale for selecting only one working day for agreement testing.
Thank you for the valuable suggestion. This will help give more details about the procedure. We have edited the same.
We have added the suggested information. Thank you.
We are obliged to rectify this. The same has been added.

Statistical Analysis:

•              Due to the limited sample size in this study, it is important to provide a justification for the chosen sample size. Include information regarding whether a power analysis was conducted.
•              I believe the study lacks sufficient statistical power for utilizing multi-rater kappa, a concern that is indeed emphasized in the discussion. It might be worth considering excluding these specific findings.
We agree with the reviewer. We did a power analysis and the same has been noted in the statistics and results part of the paper. We did not calculate the sample size as this was a pilot study.
We are obliged to rectify this and have removed the same from the manuscript.

Results:

•              Integrate relevant details about the physiotherapists into the tables or corresponding paragraphs within the Results section.
•              Organizing the kappa agreement according to the three domains of activities in Figure 1 would be beneficial. This would offer insights into the level of agreement within each domain, allowing for a comparison of agreement quality across the domains.
We are obliged to rectify this. The same has been added in the text of the results section.
Thank you for the suggestion. In our opinion, arranging the items according to the descending order brings in readability and clarity. However, the suggested information has already been added in the text section.

Discussion:

Overall, the authors effectively emphasize the feasibility of utilizing caregiver led activity logs and underscore how the design of the activity log can impact agreement. However, enhancing the discussion through a more critical comparison with existing studies would further bolster the strength of the argument.Here are some suggestions for the discussion:
•              Draw parallels with the fundamental concepts of Ecological Momentary Assessment (EMA) and elaborate on how periodic reminders every 15 minutes could have impacted the reporting within this study.
•              Compare the role of caregiver burden and recall burden in subjective reporting studies conducted in similar and other clinical populations.
•              Address the learning curve associated with reporting multiple activities by caregivers. The limited reporting duration in this single-day study may not have allowed caregivers to fully grasp the intricacies of reporting various activities, especially if a change in caregivers occurred during the day.
•              A discussion on alternative activity tracking methods, such as wearable sensors, should have been included.
•              Include a discussion of the rationale behind selecting specific activities, particularly during the initial phase, and its influence on the reporting process. For instance, considering that physiotherapists were unable to access the bathroom area, consolidating toileting-related activities into a single category could ensure equal reporting opportunities for both physiotherapists and caregivers. Likewise, it is anticipated that patients would undergo clinical monitoring and testing early in their recovery phase. Future studies may consider incorporating this aspect into the activity log to mitigate discrepancies related to this particular activity.
Thank you. We appreciate the suggestions put forth for our discussion.
This is a very good point to add. The authors appreciate the reviewer for the suggestion. We have added details of the same.
Thank you for the suggestion. The role of caregiver and the burden has already been discussed.
We agree that this would be an important finding to discuss. The same has been added.
Thank you. We agree to this. We have added the same in the discussion.
We appreciate the detailed suggestion. This is very insightful. We have added the same.
Competing Interests: None declared Close
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COMMENTS ON THIS REPORT

Author Response 10 Nov 2023

John M Solomon, Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, 576104, India

10 Nov 2023

Author Response
We, the authors, convey our sincere thanks to the reviewer for spending their valuable time reviewing our manuscript. We are pleased to know the suggestions/ modifications advised. The suggestions helped ... Continue reading
We, the authors, convey our sincere thanks to the reviewer for spending their valuable time reviewing our manuscript. We are pleased to know the suggestions/ modifications advised. The suggestions helped to enhance the quality of the manuscript. All the suggestions were incorporated/ addressed in the revised manuscript. Our response can be identified below in italics and bold.

Title: Consider adding "Pilot" to the title due to the sample size.

Thank you, we agree. We have made a request to the journal for a change in title.

Abstract: Well-written, minor suggestions:

•              Consider adding "early phase" before "hospital settings" to distinguish from outpatient rehabilitation.
•              Insert "across one day" before "every 15 minutes" for clarity
•              Include brief demographics for physiotherapists as participants.
The authors would like to thank the reviewer for the suggestion. The suggested changes have been incorporated into the abstract.

Introduction:

Paragraph 1: Please incorporate stroke statistics specific to India to substantiate the study's relevance. Utilize percentages to illustrate the impact, particularly when stating that "stroke survivors have significantly reduced activity levels."
•              Define "early phase" at the outset to enhance the paper's readability.
Paragraph 2: Expand on the benefits of increased activity during the acute phase of stroke recovery and delineate the factors that limit activity, especially in the post-acute phase.
Paragraph 3: Briefly talk about the different tools used for behavioural mapping such as video recording, checklists, wearable devices etc., with a brief discussion on pros and cons for each method. Please justify why you selected checklist/log.
Thank you for this suggestion. We have added the prevalence data from India and the percentage to the statement. This brings in more clarity to the given information.
Early phase has been defined as suggested. Thank you
We appreciate this suggestion to emphasize the importance of being active and the same has been added.
We agree that the details would give a better insight. We have added more information about the different tools used.

Methods:

Inclusion criteria:
“Functionally communicate” has been used twice in the paragraph.
Include the inclusion criteria for physiotherapists, specifying their level of expertise (e.g., trained neurophysiotherapists, novice clinicians, experienced clinicians) to provide context on their participation and qualifications in the study.
Thank you for the suggestion. We have used it twice for two different population. The first one refers to the eligibility in stroke survivors and the second mentioning refers to their caregivers.
We are obliged to rectify this. The same has been added in the methods section.

Outcome:

•              Elaborate on the process of developing the activity log, specifying whether the validation involved face validation or content validation, to enhance the clarity and rigor of the log development.
•              Specify whether the testing involving 20 stroke patients was related to assessing the practicality and usability of the log. This clarification will provide a better understanding of the purpose and focus of the testing phase.
•              Finally, explain why exercise was categorized separately from therapies in the activity log. Given that therapies often encompass exercise in the early phase, clarify the rationale for this distinction and consider discussing how this categorization may have contributed to any discrepancies observed between physiotherapists and caregivers.
The author would like to thank the reviewer for these suggestions. We have added content validation of the log chart to bring in more clarity and the objective of the testing.
We appreciate the suggestion and have added the same. However, in our opinion, these details would better suit in the manuscript pertaining to the development of the activity log chart.

Procedure:

•              Clarify whether the intern-to-patient ratio was 1:1 or if the intern monitored more than one patient on a particular day. Specify the procedure for patient monitoring when the intern had to take a break.
•              Indicate whether caregivers were provided with reminders or prompts every 15 minutes during the monitoring process.
•              Provide a rationale for selecting only one working day for agreement testing.
Thank you for the valuable suggestion. This will help give more details about the procedure. We have edited the same.
We have added the suggested information. Thank you.
We are obliged to rectify this. The same has been added.

Statistical Analysis:

•              Due to the limited sample size in this study, it is important to provide a justification for the chosen sample size. Include information regarding whether a power analysis was conducted.
•              I believe the study lacks sufficient statistical power for utilizing multi-rater kappa, a concern that is indeed emphasized in the discussion. It might be worth considering excluding these specific findings.
We agree with the reviewer. We did a power analysis and the same has been noted in the statistics and results part of the paper. We did not calculate the sample size as this was a pilot study.
We are obliged to rectify this and have removed the same from the manuscript.

Results:

•              Integrate relevant details about the physiotherapists into the tables or corresponding paragraphs within the Results section.
•              Organizing the kappa agreement according to the three domains of activities in Figure 1 would be beneficial. This would offer insights into the level of agreement within each domain, allowing for a comparison of agreement quality across the domains.
We are obliged to rectify this. The same has been added in the text of the results section.
Thank you for the suggestion. In our opinion, arranging the items according to the descending order brings in readability and clarity. However, the suggested information has already been added in the text section.

Discussion:

Overall, the authors effectively emphasize the feasibility of utilizing caregiver led activity logs and underscore how the design of the activity log can impact agreement. However, enhancing the discussion through a more critical comparison with existing studies would further bolster the strength of the argument.Here are some suggestions for the discussion:
•              Draw parallels with the fundamental concepts of Ecological Momentary Assessment (EMA) and elaborate on how periodic reminders every 15 minutes could have impacted the reporting within this study.
•              Compare the role of caregiver burden and recall burden in subjective reporting studies conducted in similar and other clinical populations.
•              Address the learning curve associated with reporting multiple activities by caregivers. The limited reporting duration in this single-day study may not have allowed caregivers to fully grasp the intricacies of reporting various activities, especially if a change in caregivers occurred during the day.
•              A discussion on alternative activity tracking methods, such as wearable sensors, should have been included.
•              Include a discussion of the rationale behind selecting specific activities, particularly during the initial phase, and its influence on the reporting process. For instance, considering that physiotherapists were unable to access the bathroom area, consolidating toileting-related activities into a single category could ensure equal reporting opportunities for both physiotherapists and caregivers. Likewise, it is anticipated that patients would undergo clinical monitoring and testing early in their recovery phase. Future studies may consider incorporating this aspect into the activity log to mitigate discrepancies related to this particular activity.
Thank you. We appreciate the suggestions put forth for our discussion.
This is a very good point to add. The authors appreciate the reviewer for the suggestion. We have added details of the same.
Thank you for the suggestion. The role of caregiver and the burden has already been discussed.
We agree that this would be an important finding to discuss. The same has been added.
Thank you. We agree to this. We have added the same in the discussion.
We appreciate the detailed suggestion. This is very insightful. We have added the same.
We, the authors, convey our sincere thanks to the reviewer for spending their valuable time reviewing our manuscript. We are pleased to know the suggestions/ modifications advised. The suggestions helped to enhance the quality of the manuscript. All the suggestions were incorporated/ addressed in the revised manuscript. Our response can be identified below in italics and bold.

Title: Consider adding "Pilot" to the title due to the sample size.

Thank you, we agree. We have made a request to the journal for a change in title.

Abstract: Well-written, minor suggestions:

•              Consider adding "early phase" before "hospital settings" to distinguish from outpatient rehabilitation.
•              Insert "across one day" before "every 15 minutes" for clarity
•              Include brief demographics for physiotherapists as participants.
The authors would like to thank the reviewer for the suggestion. The suggested changes have been incorporated into the abstract.

Introduction:

Paragraph 1: Please incorporate stroke statistics specific to India to substantiate the study's relevance. Utilize percentages to illustrate the impact, particularly when stating that "stroke survivors have significantly reduced activity levels."
•              Define "early phase" at the outset to enhance the paper's readability.
Paragraph 2: Expand on the benefits of increased activity during the acute phase of stroke recovery and delineate the factors that limit activity, especially in the post-acute phase.
Paragraph 3: Briefly talk about the different tools used for behavioural mapping such as video recording, checklists, wearable devices etc., with a brief discussion on pros and cons for each method. Please justify why you selected checklist/log.
Thank you for this suggestion. We have added the prevalence data from India and the percentage to the statement. This brings in more clarity to the given information.
Early phase has been defined as suggested. Thank you
We appreciate this suggestion to emphasize the importance of being active and the same has been added.
We agree that the details would give a better insight. We have added more information about the different tools used.

Methods:

Inclusion criteria:
“Functionally communicate” has been used twice in the paragraph.
Include the inclusion criteria for physiotherapists, specifying their level of expertise (e.g., trained neurophysiotherapists, novice clinicians, experienced clinicians) to provide context on their participation and qualifications in the study.
Thank you for the suggestion. We have used it twice for two different population. The first one refers to the eligibility in stroke survivors and the second mentioning refers to their caregivers.
We are obliged to rectify this. The same has been added in the methods section.

Outcome:

•              Elaborate on the process of developing the activity log, specifying whether the validation involved face validation or content validation, to enhance the clarity and rigor of the log development.
•              Specify whether the testing involving 20 stroke patients was related to assessing the practicality and usability of the log. This clarification will provide a better understanding of the purpose and focus of the testing phase.
•              Finally, explain why exercise was categorized separately from therapies in the activity log. Given that therapies often encompass exercise in the early phase, clarify the rationale for this distinction and consider discussing how this categorization may have contributed to any discrepancies observed between physiotherapists and caregivers.
The author would like to thank the reviewer for these suggestions. We have added content validation of the log chart to bring in more clarity and the objective of the testing.
We appreciate the suggestion and have added the same. However, in our opinion, these details would better suit in the manuscript pertaining to the development of the activity log chart.

Procedure:

•              Clarify whether the intern-to-patient ratio was 1:1 or if the intern monitored more than one patient on a particular day. Specify the procedure for patient monitoring when the intern had to take a break.
•              Indicate whether caregivers were provided with reminders or prompts every 15 minutes during the monitoring process.
•              Provide a rationale for selecting only one working day for agreement testing.
Thank you for the valuable suggestion. This will help give more details about the procedure. We have edited the same.
We have added the suggested information. Thank you.
We are obliged to rectify this. The same has been added.

Statistical Analysis:

•              Due to the limited sample size in this study, it is important to provide a justification for the chosen sample size. Include information regarding whether a power analysis was conducted.
•              I believe the study lacks sufficient statistical power for utilizing multi-rater kappa, a concern that is indeed emphasized in the discussion. It might be worth considering excluding these specific findings.
We agree with the reviewer. We did a power analysis and the same has been noted in the statistics and results part of the paper. We did not calculate the sample size as this was a pilot study.
We are obliged to rectify this and have removed the same from the manuscript.

Results:

•              Integrate relevant details about the physiotherapists into the tables or corresponding paragraphs within the Results section.
•              Organizing the kappa agreement according to the three domains of activities in Figure 1 would be beneficial. This would offer insights into the level of agreement within each domain, allowing for a comparison of agreement quality across the domains.
We are obliged to rectify this. The same has been added in the text of the results section.
Thank you for the suggestion. In our opinion, arranging the items according to the descending order brings in readability and clarity. However, the suggested information has already been added in the text section.

Discussion:

Overall, the authors effectively emphasize the feasibility of utilizing caregiver led activity logs and underscore how the design of the activity log can impact agreement. However, enhancing the discussion through a more critical comparison with existing studies would further bolster the strength of the argument.Here are some suggestions for the discussion:
•              Draw parallels with the fundamental concepts of Ecological Momentary Assessment (EMA) and elaborate on how periodic reminders every 15 minutes could have impacted the reporting within this study.
•              Compare the role of caregiver burden and recall burden in subjective reporting studies conducted in similar and other clinical populations.
•              Address the learning curve associated with reporting multiple activities by caregivers. The limited reporting duration in this single-day study may not have allowed caregivers to fully grasp the intricacies of reporting various activities, especially if a change in caregivers occurred during the day.
•              A discussion on alternative activity tracking methods, such as wearable sensors, should have been included.
•              Include a discussion of the rationale behind selecting specific activities, particularly during the initial phase, and its influence on the reporting process. For instance, considering that physiotherapists were unable to access the bathroom area, consolidating toileting-related activities into a single category could ensure equal reporting opportunities for both physiotherapists and caregivers. Likewise, it is anticipated that patients would undergo clinical monitoring and testing early in their recovery phase. Future studies may consider incorporating this aspect into the activity log to mitigate discrepancies related to this particular activity.
Thank you. We appreciate the suggestions put forth for our discussion.
This is a very good point to add. The authors appreciate the reviewer for the suggestion. We have added details of the same.
Thank you for the suggestion. The role of caregiver and the burden has already been discussed.
We agree that this would be an important finding to discuss. The same has been added.
Thank you. We agree to this. We have added the same in the discussion.
We appreciate the detailed suggestion. This is very insightful. We have added the same.
Competing Interests: None declared Close
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Reviewer Report 04 Aug 2023

Shuanglan Lin, Chongqing Medical University, Chongqing, China

Not Approved

https://doi.org/10.5256/f1000research.136897.r188815

Summary
Thank you for the invitation to review this paper. The paper might provide evidence about an alternative option to address activity monitoring in the clinical setting by caregivers (especially in some activities such as bathing and dressing), as this could be time-consuming for healthcare professionals. However, the research methodology and the small sample size in the paper might result in a lack of credibility and validation of the findings. The details of the comments are listed as follows:

Introduction

Please provide more information about the stroke status and stroke survivors in India since the study was conducted there.

Eligibility criteria

Please list the inclusion and exclusion criteria for the participants to help readers better understand this section.

Outcome

Please clarify the specific activities included in the physical, cognitive and social components.
Please describe the log chart’s validation process and provide more information about the experts.

Procedure

Please clarify if the caregivers and physiotherapists received the same training about using the activity log chart to ensure activity marking consistency during the implementation.
A single-day observation of activities among 17 stroke survivors might not provide enough evidence and draw a solid conclusion for the study. Plus, behavioural mapping is a subjective process that can lead to variability during observations.

Results

In Figure 1, it’s better to categorise all the recorded activities under the three components to help readers better understand “the agreement of activities under physical, cognitive and social domains were 42, 38 and 43%, respectively”.
I suggest analysing the factors that cause the inconsistency of agreement between caregivers and the physiotherapist, such as the physiotherapist who have received professional training and better understands different activities, or whether the caregivers’ educational background will lead to the deviation of observation.

Discussion

“Both the physiotherapist and the caregiver did not complete all observations” implies that the study’s observations were done only on a single day is not enough to conclude.
As some of the toiletry activities were monitored only by the caregivers, there is still a potential for caregivers to perform behavioural mapping of stroke in the clinical after clarifying and addressing the factors that caused the discrepancy of agreement between caregivers and the physiotherapist.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Stroke, stroke transitional care, data analysis

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Reviewer Report 03 Aug 2023

Jigna Patel, Rutgers University, Newark, New Jersey, USA

Approved

https://doi.org/10.5256/f1000research.136897.r188821

This is a simple study design that asks an important question. Specifically, the authors compared the activity monitoring of stroke survivors by caregivers and physiotherapists in a hospital setting. The amount of activity performed by stroke survivors early after stroke may affect long term recovery, thus activity monitoring by caregivers can provide an alternate means of tracking this measure. The authors found a 60% agreement between the physiotherapists and the caregivers, using Kappa statistics. The study design has some limitations which are explained by the authors.

Minor comments:

The second sentence in second paragraph of introduction is awkward. Are you trying to say there is evidence that recovery happens rapidly in the acute phase? Please reword.
Last sentence in introduction should say amount of 'activity' not 'activities'.
Remove the word 'By' at the beginning of the first sentence in the fourth paragraph of introduction.
In the eligibility section, you use the word 'supratentorial', so only cortical strokes included? Please clarify.
Procedure section: change sentences to, 'patients and caregivers were given explanations about the study'.

I approve this study as is, with the changes noted in the minor comments section.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Neurorehabilitation and neuroscience and cardiopulmonary PT.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report 01 Jun 2023

Lucian Bezuidenhout, Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden

Not Approved

https://doi.org/10.5256/f1000research.136897.r170683

Summary
Thank you for the opportunity to review this paper. Overall, the paper tackles an interesting topic, which is comparing the activity monitoring of stroke survivors by physiotherapists and caregivers. While this is a relevant topic and has some merit since caregiver monitoring can potentially be cost-effective and time efficient, however, there are some major concerns that I would like the authors to clarify. More specifically, regarding the methods used. The authors only used 1 day, although I don’t agree with 1 day being a valid measurement period for 17 stroke survivors. The authors need to strongly justify this, especially due to the subjectivity of rating by both the physios and caregivers and the experience of the caregivers in using the rating tool. In addition to this, there is missing data on observing (i.e. toileting, bathing, testing). The hypothesis of the authors also assumes that caregivers will be there to monitor the patients all day around, which is not always possible.

Abstract

The first line of the conclusion "There was moderate agreement between the physiotherapist and caregiver for activity monitoring of stroke survivors" is rather a result than a conclusion. I suggest the authors rephrase the conclusion to conclude the overall outcome of their study.

Introduction

In the first paragraph, the authors write about the global and European prevalence of stroke. While this is good, I suggest the authors also add about the prevalence of stroke in India, since this is where the study was conducted.
In the second paragraph, the authors address the physical (in)activity of people with stroke during inpatient rehab. Are there any recommendations for PA during this period for stroke survivors? i.e. number of steps per day or min spent in different PA levels for example?
In the third paragraph, the authors briefly touch on the behavioral mapping tool. I think this paragraph could be strengthened by expanding on this tool, i.e., what does it consist of? Also, the authors need to address previous studies that have used this tool in people with stroke, what have they found? Are there previous studies that have done something like your study?

Methods
In the 'Eligibility criteria' paragraph:

Can the authors give examples of who the caregivers could be?
Also, can the authors first list all the inclusion criteria and then list the exclusion criteria? Was understanding or previous experience of the activity log an inclusion criterion?

In the 'Outcome' paragraph:

Did the caregivers or the physios get any training on using the activity log?
The authors mention that "the log chart was sent to 15 experts for validation". How was this done? Who were the experts?

Procedure

The authors mention that "The observations were carried out every 15 min". What happened when the caregivers or physios had to take a break i.e. go to the toilet or lunch break?
Is one day enough to make an overall conclusion? The authors need to strongly justify why they only did 1 day of measurements.

Results

Figure 1, can the authors separate (group) the different activities into the 3 different domains i.e. physical, cognitive and social? Therefore, it would be easier to see which of these domains had the best agreement or the worst.
It would also be interesting to look at the agreement over the course of the day. For example, did the accuracy decrease over the day i.e., did the raters get tired of observing the people with stroke?

Discussion

The discussion lacks comparison to other studies that conducted similar observations. What did they find compared to your results?
Have the authors thought about using accelerometry to measure activity? Although the accelerometry might not be able to yield the exact activity being done, it could give an overall PA output, which could be a good marker for measuring changes in activity levels. I think this is worth a mention in the discussion.
Although I think one can't really draw any conclusion from 1 day of observations, what does it mean clinically that there is a 60% agreement between the physiotherapist and the caregivers? Is this enough? What can be done to increase this agreement? Is this a future valid technique?
One of the possible clinical implications of this study is if the caregivers don't want to participate in the activity logging. Maybe they just want to be present and support the person affected by stroke.
This paper does not have an overall conclusion.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Physical activity, Stroke, neurological diseases. Data analysis procedures, scientific methods.

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Version 2

VERSION 2 PUBLISHED 27 Oct 2022

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Version 1 27 Oct 22	read	read	read	read

Lucian Bezuidenhout, Karolinska Institutet, Stockholm, Sweden
Jigna Patel, Rutgers University, Newark, USA
Shuanglan Lin, Chongqing Medical University, Chongqing, China
Ketaki Inamdar, Virginia Commonwealth University, Richmond, USA

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Reviewer Report

5 Views

10 Nov 2023 | for Version 2

Jigna Patel, Rutgers University, Newark, New Jersey, USA

5 Views Cite this report Responses(0)

Approved

No further comments to make.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neurorehabilitation and neuroscience and cardiopulmonary PT.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

6 Views

10 Nov 2023 | for Version 2

Ketaki Inamdar, Virginia Commonwealth University, Richmond, Virginia, USA

6 Views Cite this report Responses(0)

Approved

The authors have done a commendable job in incorporating my feedback. The revised version has a more robust introduction and discussion section, with more balanced conclusions. Here are some minor suggestions for the authors.

Consider rephrasing the last line of the first paragraph in the Introduction section; it appears to contain a minor grammatical error.
Given the exclusion of the multi-rater kappa analysis for different time-points, kindly remove it from the analysis plan.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

17 Views

12 Oct 2023 | for Version 1

Ketaki Inamdar, Virginia Commonwealth University, Richmond, Virginia, USA

17 Views Cite this report Responses(1)

Approved With Reservations

Consider adding "Pilot" to the title due to the sample size.

Abstract:
Well-written, minor suggestions:

Consider adding "early phase" before "hospital settings" to distinguish from outpatient rehabilitation.
Insert "across one day" before "every 15 minutes" for clarity.
Include brief demographics for physiotherapists as participants.

Define "early phase" at the outset to enhance the paper's readability.

Paragraph 2:

Expand on the benefits of increased activity during the acute phase of stroke recovery and delineate the factors that limit activity, especially in the post-acute phase.

Paragraph 3:

Briefly talk about the different tools used for behavioural mapping such as video recording, checklists, wearable devices etc., with a brief discussion on pros and cons for each method. Please justify why you selected checklist/log.

Methods:
Inclusion criteria:

“Functionally communicate” has been used twice in the paragraph.
Include the inclusion criteria for physiotherapists, specifying their level of expertise (e.g., trained neurophysiotherapists, novice clinicians, experienced clinicians) to provide context on their participation and qualifications in the study.

Outcome:

Elaborate on the process of developing the activity log, specifying whether the validation involved face validation or content validation, to enhance the clarity and rigor of the log development.
Specify whether the testing involving 20 stroke patients was related to assessing the practicality and usability of the log. This clarification will provide a better understanding of the purpose and focus of the testing phase.
Finally, explain why exercise was categorized separately from therapies in the activity log. Given that therapies often encompass exercise in the early phase, clarify the rationale for this distinction and consider discussing how this categorization may have contributed to any discrepancies observed between physiotherapists and caregivers.

Procedure:

Clarify whether the intern-to-patient ratio was 1:1 or if the intern monitored more than one patient on a particular day. Specify the procedure for patient monitoring when the intern had to take a break.
Indicate whether caregivers were provided with reminders or prompts every 15 minutes during the monitoring process.
Provide a rationale for selecting only one working day for agreement testing.

Statistical Analysis:

Due to the limited sample size in this study, it is important to provide a justification for the chosen sample size. Include information regarding whether a power analysis was conducted.
I believe the study lacks sufficient statistical power for utilizing multi-rater kappa, a concern that is indeed emphasized in the discussion. It might be worth considering excluding these specific findings.

Results:

Integrate relevant details about the physiotherapists into the tables or corresponding paragraphs within the Results section.
Organizing the kappa agreement according to the three domains of activities in Figure 1 would be beneficial. This would offer insights into the level of agreement within each domain, allowing for a comparison of agreement quality across the domains.

Draw parallels with the fundamental concepts of Ecological Momentary Assessment (EMA) and elaborate on how periodic reminders every 15 minutes could have impacted the reporting within this study.
Compare the role of caregiver burden and recall burden in subjective reporting studies conducted in similar and other clinical populations.
Address the learning curve associated with reporting multiple activities by caregivers. The limited reporting duration in this single-day study may not have allowed caregivers to fully grasp the intricacies of reporting various activities, especially if a change in caregivers occurred during the day.
A discussion on alternative activity tracking methods, such as wearable sensors, should have been included.
Include a discussion of the rationale behind selecting specific activities, particularly during the initial phase, and its influence on the reporting process. For instance, considering that physiotherapists were unable to access the bathroom area, consolidating toileting-related activities into a single category could ensure equal reporting opportunities for both physiotherapists and caregivers. Likewise, it is anticipated that patients would undergo clinical monitoring and testing early in their recovery phase. Future studies may consider incorporating this aspect into the activity log to mitigate discrepancies related to this particular activity.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neurophysiotherapy, activity monitoring

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Author Response

10 Nov 2023

John M Solomon, Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, 576104, India

We, the authors, convey our sincere thanks to the reviewer for spending their valuable time reviewing our manuscript. We are pleased to know the suggestions/ modifications advised. The suggestions helped to enhance the quality of the manuscript. All the suggestions were incorporated/ addressed in the revised manuscript. Our response can be identified below in italics and bold.

Title: Consider adding "Pilot" to the title due to the sample size.

Thank you, we agree. We have made a request to the journal for a change in title.

Abstract: Well-written, minor suggestions:

•              Consider adding "early phase" before "hospital settings" to distinguish from outpatient rehabilitation.
•              Insert "across one day" before "every 15 minutes" for clarity
•              Include brief demographics for physiotherapists as participants.
The authors would like to thank the reviewer for the suggestion. The suggested changes have been incorporated into the abstract.

Introduction:

Paragraph 1: Please incorporate stroke statistics specific to India to substantiate the study's relevance. Utilize percentages to illustrate the impact, particularly when stating that "stroke survivors have significantly reduced activity levels."
• Define "early phase" at the outset to enhance the paper's readability.
Paragraph 2: Expand on the benefits of increased activity during the acute phase of stroke recovery and delineate the factors that limit activity, especially in the post-acute phase.
Paragraph 3: Briefly talk about the different tools used for behavioural mapping such as video recording, checklists, wearable devices etc., with a brief discussion on pros and cons for each method. Please justify why you selected checklist/log.
Thank you for this suggestion. We have added the prevalence data from India and the percentage to the statement. This brings in more clarity to the given information.
Early phase has been defined as suggested. Thank you
We appreciate this suggestion to emphasize the importance of being active and the same has been added.
We agree that the details would give a better insight. We have added more information about the different tools used.

Methods:

Inclusion criteria:
“Functionally communicate” has been used twice in the paragraph.
Include the inclusion criteria for physiotherapists, specifying their level of expertise (e.g., trained neurophysiotherapists, novice clinicians, experienced clinicians) to provide context on their participation and qualifications in the study.
Thank you for the suggestion. We have used it twice for two different population. The first one refers to the eligibility in stroke survivors and the second mentioning refers to their caregivers.
We are obliged to rectify this. The same has been added in the methods section.

Outcome:

•              Elaborate on the process of developing the activity log, specifying whether the validation involved face validation or content validation, to enhance the clarity and rigor of the log development.
•              Specify whether the testing involving 20 stroke patients was related to assessing the practicality and usability of the log. This clarification will provide a better understanding of the purpose and focus of the testing phase.
•              Finally, explain why exercise was categorized separately from therapies in the activity log. Given that therapies often encompass exercise in the early phase, clarify the rationale for this distinction and consider discussing how this categorization may have contributed to any discrepancies observed between physiotherapists and caregivers.
The author would like to thank the reviewer for these suggestions. We have added content validation of the log chart to bring in more clarity and the objective of the testing.
We appreciate the suggestion and have added the same. However, in our opinion, these details would better suit in the manuscript pertaining to the development of the activity log chart.

Procedure:

•              Clarify whether the intern-to-patient ratio was 1:1 or if the intern monitored more than one patient on a particular day. Specify the procedure for patient monitoring when the intern had to take a break.
•              Indicate whether caregivers were provided with reminders or prompts every 15 minutes during the monitoring process.
•              Provide a rationale for selecting only one working day for agreement testing.
Thank you for the valuable suggestion. This will help give more details about the procedure. We have edited the same.
We have added the suggested information. Thank you.
We are obliged to rectify this. The same has been added.

Statistical Analysis:

• Due to the limited sample size in this study, it is important to provide a justification for the chosen sample size. Include information regarding whether a power analysis was conducted.
• I believe the study lacks sufficient statistical power for utilizing multi-rater kappa, a concern that is indeed emphasized in the discussion. It might be worth considering excluding these specific findings.
We agree with the reviewer. We did a power analysis and the same has been noted in the statistics and results part of the paper. We did not calculate the sample size as this was a pilot study.
We are obliged to rectify this and have removed the same from the manuscript.

Results:

• Integrate relevant details about the physiotherapists into the tables or corresponding paragraphs within the Results section.
• Organizing the kappa agreement according to the three domains of activities in Figure 1 would be beneficial. This would offer insights into the level of agreement within each domain, allowing for a comparison of agreement quality across the domains.
We are obliged to rectify this. The same has been added in the text of the results section.
Thank you for the suggestion. In our opinion, arranging the items according to the descending order brings in readability and clarity. However, the suggested information has already been added in the text section.

Discussion:

Overall, the authors effectively emphasize the feasibility of utilizing caregiver led activity logs and underscore how the design of the activity log can impact agreement. However, enhancing the discussion through a more critical comparison with existing studies would further bolster the strength of the argument.Here are some suggestions for the discussion:
•              Draw parallels with the fundamental concepts of Ecological Momentary Assessment (EMA) and elaborate on how periodic reminders every 15 minutes could have impacted the reporting within this study.
•              Compare the role of caregiver burden and recall burden in subjective reporting studies conducted in similar and other clinical populations.
•              Address the learning curve associated with reporting multiple activities by caregivers. The limited reporting duration in this single-day study may not have allowed caregivers to fully grasp the intricacies of reporting various activities, especially if a change in caregivers occurred during the day.
•              A discussion on alternative activity tracking methods, such as wearable sensors, should have been included.
•              Include a discussion of the rationale behind selecting specific activities, particularly during the initial phase, and its influence on the reporting process. For instance, considering that physiotherapists were unable to access the bathroom area, consolidating toileting-related activities into a single category could ensure equal reporting opportunities for both physiotherapists and caregivers. Likewise, it is anticipated that patients would undergo clinical monitoring and testing early in their recovery phase. Future studies may consider incorporating this aspect into the activity log to mitigate discrepancies related to this particular activity.
Thank you. We appreciate the suggestions put forth for our discussion.
This is a very good point to add. The authors appreciate the reviewer for the suggestion. We have added details of the same.
Thank you for the suggestion. The role of caregiver and the burden has already been discussed.
We agree that this would be an important finding to discuss. The same has been added.
Thank you. We agree to this. We have added the same in the discussion.
We appreciate the detailed suggestion. This is very insightful. We have added the same.

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Competing Interests

None declared

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Reviewer Report

14 Views

04 Aug 2023 | for Version 1

Shuanglan Lin, Chongqing Medical University, Chongqing, China

14 Views Cite this report Responses(0)

Not Approved

Please provide more information about the stroke status and stroke survivors in India since the study was conducted there.

Eligibility criteria

Please list the inclusion and exclusion criteria for the participants to help readers better understand this section.

Outcome

Please clarify the specific activities included in the physical, cognitive and social components.
Please describe the log chart’s validation process and provide more information about the experts.

Procedure

Please clarify if the caregivers and physiotherapists received the same training about using the activity log chart to ensure activity marking consistency during the implementation.
A single-day observation of activities among 17 stroke survivors might not provide enough evidence and draw a solid conclusion for the study. Plus, behavioural mapping is a subjective process that can lead to variability during observations.

Results

In Figure 1, it’s better to categorise all the recorded activities under the three components to help readers better understand “the agreement of activities under physical, cognitive and social domains were 42, 38 and 43%, respectively”.
I suggest analysing the factors that cause the inconsistency of agreement between caregivers and the physiotherapist, such as the physiotherapist who have received professional training and better understands different activities, or whether the caregivers’ educational background will lead to the deviation of observation.

Discussion

“Both the physiotherapist and the caregiver did not complete all observations” implies that the study’s observations were done only on a single day is not enough to conclude.
As some of the toiletry activities were monitored only by the caregivers, there is still a potential for caregivers to perform behavioural mapping of stroke in the clinical after clarifying and addressing the factors that caused the discrepancy of agreement between caregivers and the physiotherapist.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Stroke, stroke transitional care, data analysis

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Reviewer Report

15 Views

03 Aug 2023 | for Version 1

Jigna Patel, Rutgers University, Newark, New Jersey, USA

15 Views Cite this report Responses(0)

Approved

The second sentence in second paragraph of introduction is awkward. Are you trying to say there is evidence that recovery happens rapidly in the acute phase? Please reword.
Last sentence in introduction should say amount of 'activity' not 'activities'.
Remove the word 'By' at the beginning of the first sentence in the fourth paragraph of introduction.
In the eligibility section, you use the word 'supratentorial', so only cortical strokes included? Please clarify.
Procedure section: change sentences to, 'patients and caregivers were given explanations about the study'.

I approve this study as is, with the changes noted in the minor comments section.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neurorehabilitation and neuroscience and cardiopulmonary PT.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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16 Views

01 Jun 2023 | for Version 1

Lucian Bezuidenhout, Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden

16 Views Cite this report Responses(0)

Not Approved

The first line of the conclusion "There was moderate agreement between the physiotherapist and caregiver for activity monitoring of stroke survivors" is rather a result than a conclusion. I suggest the authors rephrase the conclusion to conclude the overall outcome of their study.

Introduction

In the first paragraph, the authors write about the global and European prevalence of stroke. While this is good, I suggest the authors also add about the prevalence of stroke in India, since this is where the study was conducted.
In the second paragraph, the authors address the physical (in)activity of people with stroke during inpatient rehab. Are there any recommendations for PA during this period for stroke survivors? i.e. number of steps per day or min spent in different PA levels for example?
In the third paragraph, the authors briefly touch on the behavioral mapping tool. I think this paragraph could be strengthened by expanding on this tool, i.e., what does it consist of? Also, the authors need to address previous studies that have used this tool in people with stroke, what have they found? Are there previous studies that have done something like your study?

Methods
In the 'Eligibility criteria' paragraph:

Can the authors give examples of who the caregivers could be?
Also, can the authors first list all the inclusion criteria and then list the exclusion criteria? Was understanding or previous experience of the activity log an inclusion criterion?

In the 'Outcome' paragraph:

Did the caregivers or the physios get any training on using the activity log?
The authors mention that "the log chart was sent to 15 experts for validation". How was this done? Who were the experts?

Procedure

The authors mention that "The observations were carried out every 15 min". What happened when the caregivers or physios had to take a break i.e. go to the toilet or lunch break?
Is one day enough to make an overall conclusion? The authors need to strongly justify why they only did 1 day of measurements.

Results

Figure 1, can the authors separate (group) the different activities into the 3 different domains i.e. physical, cognitive and social? Therefore, it would be easier to see which of these domains had the best agreement or the worst.
It would also be interesting to look at the agreement over the course of the day. For example, did the accuracy decrease over the day i.e., did the raters get tired of observing the people with stroke?

Discussion

The discussion lacks comparison to other studies that conducted similar observations. What did they find compared to your results?
Have the authors thought about using accelerometry to measure activity? Although the accelerometry might not be able to yield the exact activity being done, it could give an overall PA output, which could be a good marker for measuring changes in activity levels. I think this is worth a mention in the discussion.
Although I think one can't really draw any conclusion from 1 day of observations, what does it mean clinically that there is a 60% agreement between the physiotherapist and the caregivers? Is this enough? What can be done to increase this agreement? Is this a future valid technique?
One of the possible clinical implications of this study is if the caregivers don't want to participate in the activity logging. Maybe they just want to be present and support the person affected by stroke.
This paper does not have an overall conclusion.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Physical activity, Stroke, neurological diseases. Data analysis procedures, scientific methods.

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Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Johnson W, Onuma O, Owolabi M, et al.: Stroke: a global response is needed. Bull. World Health Organ. 2016; 94: 634–634A. PubMed Abstract | Publisher Full Text

[2] 2. Wafa HA, Wolfe CDA, Emmett E, et al.: Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years. Stroke. 2020; 51: 2418–2427. PubMed Abstract | Publisher Full Text

[3] 3. Taylor-Rowan M, Cuthbertson G, Keir R, et al.: The prevalence of frailty among acute stroke patients, and evaluation of method of assessment. Clin. Rehabil. 2019; 33: 1688–1696. PubMed Abstract | Publisher Full Text

[4] 4. Dorsch S, Ada L, Canning CG: Lower Limb Strength Is Significantly Impaired in All Muscle Groups in Ambulatory People With Chronic Stroke: A Cross-Sectional Study. Arch. Phys. Med. Rehabil. 2016; 97: 522–527. PubMed Abstract | Publisher Full Text

[5] 5. Greenham M, Gordon AL, Cooper A, et al.: Social functioning following pediatric stroke: contribution of neurobehavioral impairment. Dev. Neuropsychol. 2018; 43: 312–328. PubMed Abstract | Publisher Full Text

[6] 6. Middaugh SJ, Whitehead WE, Burgio KL, et al.: Biofeedback in treatment of urinary incontinence in stroke patients. Biofeedback Self Regul. 1989; 14: 3–19. PubMed Abstract | Publisher Full Text

[7] 7. Field MJ, Gebruers N, Shanmuga Sundaram T, et al.: Physical Activity after Stroke: A Systematic Review and Meta-Analysis. ISRN Stroke. 2013; 2013: 1–13. Publisher Full Text

[8] 8. de Leciñana MA , Gutiéérrez-Fernández M, Romano M, et al.: Strategies to Improve Recovery in Acute Ischemic Stroke Patients: Iberoamerican Stroke Group Consensus. Int. J. Stroke. 2014; 9: 503–513. PubMed Abstract | Publisher Full Text

[9] 9. Bernhardt J, Dewey H, Thrift A, et al.: Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke. 2004; 35: 1005–1009. Publisher Full Text

[10] 10. Kunkel D, Fitton C, Burnett M, et al.: Physical inactivity post-stroke: a 3-year longitudinal study. Disabil. Rehabil. 2015; 37: 304–310. PubMed Abstract | Publisher Full Text

[11] 11. Ezeugwu VE, Manns PJ: Sleep Duration, Sedentary Behavior, Physical Activity, and Quality of Life after Inpatient Stroke Rehabilitation. J. Stroke Cerebrovasc. Dis. 2017; 26: 2004–2012. PubMed Abstract | Publisher Full Text

[12] 12. Askim T, Bernhardt J, Salvesen Ø, et al.: Physical Activity Early after Stroke and Its Association to Functional Outcome 3 Months Later. J. Stroke Cerebrovasc. Dis. 2014; 23: e305–e312. PubMed Abstract | Publisher Full Text

[13] 13. Alawieh A, Zhao J, Feng W: Factors affecting post-stroke motor recovery: Implications on neurotherapy after brain injury. Behav. Brain Res. 2018; 340: 94–101. PubMed Abstract | Publisher Full Text

[14] 14. Ng CF:Behavioral Mapping and Tracking. Research Methods for Environmental Psychology. John Wiley & Sons, Ltd;pp. 29–51. Publisher Full Text

[15] 15. Cosco NG, Moore RC, Islam MZ: Behavior Mapping: A Method for Linking Preschool Physical Activity and Outdoor Design. Med. Sci. Sports Exerc. 2010; 42: 513–519. Publisher Full Text

[16] 16. Cox A, Loebach J, Little S: Understanding the Nature Play Milieu: Using Behavior Mapping to Investigate Children’s Activities in Outdoor Play Spaces. Child. Youth Environ. 2018; 28: 232–261.

[17] 17. Alam BM: Application of Geographic Information Systems. BoD – Books on Demand;2012. Publisher Full Text

[18] 18. Janssen H, Ada L, Bernhardt J, et al.: An enriched environment increases activity in stroke patients undergoing rehabilitation in a mixed rehabilitation unit: a pilot non-randomized controlled trial. Disabil. Rehabil. 2014; 36: 255–262. PubMed Abstract | Publisher Full Text

[19] 19. Rosbergen IC, Grimley RS, Hayward KS, et al.: Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before–after pilot study. Clin. Rehabil. 2017; 31: 1516–1528. PubMed Abstract | Publisher Full Text

[20] 20. Valkenet K, Bor P, van Delft L , et al.: Measuring physical activity levels in hospitalized patients: a comparison between behavioural mapping and data from an accelerometer. Clin. Rehabil. 2019; 33: 1233–1240. PubMed Abstract | Publisher Full Text

[21] 21. Mackey F, Ada L, Heard R, et al.: Stroke rehabilitation: Are highly structured units more conducive to physical activity than less structured units? Arch. Phys. Med. Rehabil. 1996; 77: 1066–1070. PubMed Abstract | Publisher Full Text

[22] 22. Prakash V, Shah MA, Hariohm K: Family’s presence associated with increased physical activity in patients with acute stroke: an observational study. Braz. J. Phys. Ther. 2016; 20: 306–311. PubMed Abstract | Publisher Full Text

[23] 23. Anåker A, von Koch L , Sjöstrand C, et al.: The physical environment and patients’ activities and care: A comparative case study at three newly built stroke units. J. Adv. Nurs. 2018; 74: 1919–1931. PubMed Abstract | Publisher Full Text

[24] 24. Pérez-Cruz M, Parra-Anguita L, López-Martínez C, et al.: Burden and Anxiety in Family Caregivers in the Hospital That Debut in Caregiving. IJERPH. 2019; 16: 3977. PubMed Abstract | Publisher Full Text

[25] 25. Sim J, Wright CC: The Kappa Statistic in Reliability Studies: Use, Interpretation, and Sample Size Requirements. Phys. Ther. 2005; 85: 257–268. PubMed Abstract | Publisher Full Text

[26] 26. Anderson WH, Ha JW, Couper DJ, et al.: Variability in objective and subjective measures affects baseline values in studies of patients with COPD. PLoS One. 2017; 12: e0184606. PubMed Abstract | Publisher Full Text

[27] 27. Hsu T, Nathwani N, Loscalzo M, et al.: Understanding Caregiver Quality of Life in Caregivers of Hospitalized Older Adults With Cancer. J. Am. Geriatr. Soc. 2019; 67: 978–986. PubMed Abstract | Publisher Full Text

[28] 28. Plank A, Mazzoni V, Cavada L: Becoming a caregiver: new family carers’ experience during the transition from hospital to home: New family carers’ experience. J. Clin. Nurs. 2012; 21: 2072–2082. PubMed Abstract | Publisher Full Text

[29] 29. Moral-Fernández L, Frías-Osuna A, Moreno-Cámara S, et al.: The start of caring for an elderly dependent family member: a qualitative metasynthesis. BMC Geriatr. 2018; 18: 228. PubMed Abstract | Publisher Full Text

[30] 30. Junker R, Schlebusch H, Luppa PB: Point-of-Care Testing in Hospitals and Primary Care. Deutsches Aerzteblatt Online. 2010. Epub ahead of print 20 August. Publisher Full Text

[31] 31. Shankaranarayana AM:F1000 data final. figshare. [Dataset]. 2022. Publisher Full Text

Activity monitoring of stroke patients by physiotherapist and caregivers in a hospital setting

Abstract

Keywords

Introduction

Methods

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Participants

Outcome

Procedure

Statistical analysis

Results

Table 1. Demographic characteristics of the stroke survivors in the study (n=17).

Table 2. Socio-educational details of the caregivers who participated in the study (n=17).

Figure 1. Percentage agreement for different activities.

Discussion

Data availability

Underlying data

References

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