Reviewer's report
Title:Effect of Complete decongestive therapy and home program on Health-
Related Quality of Life in Post mastectomy lymphedema patients
Version:2Date:18 November 2015
Reviewer: Mary Fisher
Reviewer's report:
Major Compulsory Revisions:
Use of the English language: the errors in grammar are significant enough to
make a complete understanding of this research by the reader difficult, and
therefore cloud the significance of the findings in this study.
Abstract:
Line 35: What is meant by “Edema commonly affects….and shows impact on
quality of life”? Perhaps the authors mean to state that quality of life is negatively
impacted.
Line 43-44: statistical analyses statement is incomplete as descriptive statistics
were used to analyze participant demographics, and independent t-tests used to
evaluate group differences on patient demographics.
Line 46: More significant improvement is misleading (and reader is unable to
verify because of a lack of p-values). Perhaps stating greater improvement is a
better way to express. Remove “at 5% level”. The a priori level of significance set
at alpha .05 would be part of the statistical explanation, not results.
Line 49: It is more factual to state that results indicate intervention showed an
improved quality of life, rather than a ‘better’ quality of life.
Background:
The background is a very long 2.5 page paragraph. Please reorganize into
separate paragraphs to facilitate reader understanding of the topic.
Line 69: Clarify or operationally define “psychological morbidity”.
Line 98: Cite the evidence reported.
Lines 106-111: The lines about the QOL instruments used in this study belong in
the methods section.
Line 111-112: This statement is unclear. Please clarify what is meant by
indicating direction needed for treatment.
Methods:
A lack of clarity of when data were collected exists. This is a concluding
statement at the end of a paragraph of within procedures, but should be stated
more clearly that the study was a repeated measures study.
Line 118: Provide the reader with full information on inclusion and exclusion
criteria, and why 20 individuals were excluded (specific exclusion criteria).
Lines 122-123: Are these the inclusion criteria? This is unclear and needs to be
defined for the reader.
Line 124: How was lymphedema diagnosed? This is unclear. Was limb volume
calculated using the truncated cone formula? If not, why was the circumferential
method alone used when the truncated cone method is valid and reliable? Where
was the measurement taken?
Procedures:
Line 141: Describe in detail how the massage strokes were different than manual
lymph drainage strokes.
Line 145: Note or clarify how the compression garment worn by the control group
was different than that of the CDT group. “Hrs” should be spelled out.
Results:
This section lacks organization. It is unclear how each research question was
analyzed. Were demographic data by group analyzed by the ANOVA or
independent t-tests? Were the groups equal at baseline? Table 1 is not referred
to in the text. Were there data points for all measures for all participants for all
time periods, or were any participants lost to follow-up? If so, how was the data
handled?
No p-values are reported for any of the results. It is difficult to determine when
the significant differences are within or between groups, and at what time
periods. Post-hoc testing is not clear. If statistical significance is found within both
groups over time, it is more accurate to state which group had greater differences
in data rather than greater significance.
Organizing each paragraph to answer each research question will help the
reader understand the findings. Also, consider keeping sentence structure
parallel when reporting results to assist with reader understanding.
Discussion:
Similar to the background, this section is one long paragraph. This makes the
message confusing. Additionally, there is a lack of connection between research
cited and the findings of the study. The findings of reduced pain are not related to
any previous research. This section requires reorganization to explain the
findings of this study in light of existing research, and what is novel and important
about this particular study.
Line 217: It is not clear how hand function is enhanced through this study. Hand
function is not part of this study. What is the link between hand function and
quality of life?
Line 219-223: It is unclear what “QOL significantly improved with upper limb
lymphedema”; do the authors mean that in a group of women with upper limb
lymphedema, QOL significantly improved?
Line 230-233: It is unclear what is meant by “failed to demonstrate the efficacy
and role of individual components.” Please clarify.
Line 233-234: It is unclear what is meant by “The methodology was limited and
concurred with other researchers…” Please clarify.
Line 243-246: What is the importance of citing the different versions of the QOL
instruments? Do the newer versions assess home program impact? Or are the
authors stating that this study
was different because of the inclusion of a home program? This is not clear. It is
also unclear why there is a citation at the end of this sentence.
Line 250: How was participant adherence assessed? This is not discussed in the
methodology or results sections.
Conclusion:
There is no mention anywhere prior of what constitutes a clinically relevant
improvement in pain and QOL. The importance of pain reduction is not discussed
in this paper. Conclusion does not appear to align with results and discussion.
Limitations
Please explain the impact of the limitations of the study and plans or
recommendations for future research. Generally this is included within the
discussion, unless the limitations are a separate section per journal guidelines.
Table 1:
Suggest that this be titled: “Participant Demographics”
Groups are not defined in the table. It would be clearer for the reader to define as
CT and CDT as used in the text. N needs to be noted in the table for each group.
Note unit of measure (years).
What is test value? This is dependent on which statistical test was used, which
was not identified in the paper.
Identify that the mean (+/- standard deviation) are reported.
Table 2:
As submitted, this is unreadable due to formatting errors.
No p-values are reported to note significant differences.
This table may need to be reworked to be able to accommodate within/between
group statistical differences.
Consider feedback for Table 1 when reconstructing.
Figures:
Rather than Group A/B, title using CT or CDT as is done in the text.
Figures graphically represent the differences in improvement between groups,
but consider trying to depict this in fewer figures. There is inconsistency in the
scaling between figures, making differences seem bigger than they may be.
Need to be clear about whether the between group differences are significant.
Minor Essential Revisions:
Abstract:
Line 36: “the” needs to be placed before “relationship”
Line 43: “the” needs to be placed before “Visual Analog Scale”
Background:
Line 66: Secondary lymphedema in breast cancer survivors is not inevitable;
estimates range anywhere from 30-70% that women treated for breast cancer
will develop lymphedema.
Line 71: Remove “low”; the statement is not directional.
Line 74: an “s” is missing after “lead”
Line 79: add “, and” after “drainage” before “4)”
Line 96-97: This is a repetition of information presented earlier in the background
section.
Line 100: It is unclear where several valid instruments were used.
Line 101: Use the full name of an instrument first, and then abbreviate in
parentheses
Line 103: Comma after citations [28-35].
Line 105: Comma after FACT-B
Lines 106-111: The lines about the QOL instruments used in this study belong in
the methods section.
Line 111-112: This statement is unclear. Please clarify what is meant by
indicating direction needed for treatment.
Line 113: replace “article” with “study” or “investigation”
Line 114: CDT has not been defined.
Methods:
Line 118: Please use a colon after “groups”.
Line 125: “Participants” does not have an apostrophe after the “s”.
Lines 131-132: “Volunteered” is an odd phrasing.
Line 134: Present tense; use “are” instead of “were”.
Line 135: Begin sentence with the article “The”; remove “s” from “literates”.
Procedures:
Line 145: “Hrs” should be spelled out.
Line 151: Spell out “min”
Line 154: The description of diaphragmatic breathing is good; suggest calling it
diaphragmatic breathing. The tenses in the sentence are inconsistent; present
tense is mixed with the appropriate use of past tense.
Line 156: The correct article is “The” rather than “A” for the sentence beginning
with “A 1hour”.
Lines 158-159: “they found to be satisfactory” is unclear
Discussion
Line 211: A word is missing between “to” and “research”; make sure tense of
sentence is correct.
Line 218: Cite after Kim et al.,
Line 223: Cite after Karadibak et al.,
Line 227: Cite after Badger et al.,
Line 230: Cite after McCallin et al.,
Line 235: The correct word is “contrast” rather than “contrary”.
Line 237: Cite after Meneses and McNees
Line 239: Cite after Martin, et al.,
Line 246-248: Incomplete sentence. It is unclear what is meant by “…accurate
information on health-related quality of life outcomes among post mastectomy
lymphedema patients.”
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests