Abstract Committee Review

Thank you very much for your thoughtful revision of the abstract “Subanalysis of the therapeutic goals with GAS scale on the LINITOX study”. The revised version is substantially improved and addresses the majority of the concerns raised in the initial review. In particular, the clarification of methodology, inclusion of exact p-values with confidence intervals, cycle-to-cycle analysis, and balanced interpretation of primary vs. secondary goals have all strengthened the abstract.

At this stage, I believe the work is suitable for acceptance, pending only minor refinements:

1. GAS methodology – If available, please add a brief note on whether assessors underwent any training or calibration, or if inter-rater reliability was evaluated. This will enhance transparency.
2. Future directions – Consider adding one concise sentence highlighting potential refinements, such as weighted/hierarchical goals, integration of patient-reported GAS outcomes, or wearable gait monitoring.
3. Affiliations – Please remove duplication of “University Hospital La Princesa” for clarity.

Overall, this is a valuable and clinically relevant contribution, and I recommend acceptance with minor revisions.

Thank you very much for your thoughtful and constructive feedback on our abstract submission “Subanalysis of the therapeutic goals with GAS scale on the LINITOX study” (ID 0019). We sincerely appreciate the time and effort you dedicated to reviewing our work.

Please find attached the revised version of the abstract, where we have incorporated the suggestions provided by the Committee, including clarification of methodology, statistical reporting with p-values and confidence intervals, cycle-to-cycle interpretation, and refinement of the conclusions regarding the relevance of patient-centered goals.

We trust that the modifications address the main points raised and have strengthened the abstract. Please let us know if further adjustments are needed, as we remain at your disposal to ensure the submission fully meets the conference requirements.

With best regards,
Aránzazu Vázquez Doce

Recommendation: Major Revision

General Evaluation
This is an important and well-conceived subanalysis of the LINITOX trial. The abstract addresses a gap in the literature by examining Goal Attainment Scale (GAS) outcomes in MS patients with spastic paraparesis treated with repeated aboBoNT-A infiltrations. The focus on patient-centered therapeutic goals adds clear clinical relevance and complements traditional functional endpoints such as the 6MWT and MSWS-12.

However, several aspects require clarification and expansion before the abstract is ready for publication. Below I outline the main points that, once addressed, will substantially strengthen the abstract.

1. GAS Methodology

• Please clarify how GAS goals were selected and scored:
  • Were goals individualized with patient–clinician discussion, or standardized across all participants?
  • Who performed the scoring (patient, physician, or both)?
  • Was there any training or calibration among raters, or evaluation of inter-rater agreement?
• Because GAS is inherently subjective, transparency here will strengthen the credibility of the findings.

2. Definition of Walking Goal

• The ≥20% threshold in 6MWT is ambitious. Literature in MS and stroke suggests that 10–15% change is often considered clinically meaningful.
• Please justify the chosen threshold with references, or discuss whether this stricter cutoff may explain the relatively low attainment rate.

3. Cycle-to-Cycle Patterns

• The finding that goal attainment peaked in cycles 2–3 is clinically interesting. Consider elaborating on potential reasons, e.g.:
  • Adjustments to dose or injection pattern across cycles
  • Accumulative effect of repeated treatments
  • Patient adaptation or more realistic goal setting over time
• A figure or table showing goal attainment rates per cycle would make this clearer and more impactful.

4. Statistical Reporting

• Please include exact p-values, effect sizes, and 95% confidence intervals for primary and secondary endpoints (6MWT, MSWS-12, GAS goals).
• State whether any adjustments were made for baseline variability or cycle effects.

5. Balance in Interpretation

• The current framing emphasizes that walking goals were not frequently achieved, which could be interpreted negatively.
• Consider balancing this by highlighting that secondary goals (spasm and clonus control) were consistently achieved, providing meaningful functional benefits for patients in daily life.

6. Future Directions

• The conclusion rightly suggests refining GAS definitions. Please expand on this by proposing:
  • Weighted or hierarchical goal frameworks (primary vs secondary)
  • Incorporation of patient-reported GAS outcomes
  • Use of digital gait monitoring/wearable devices for more sensitive and objective outcome assessment

7. Minor Revisions

• Affiliations: please remove duplication of “University Hospital La Princesa.”
• Terminology: standardize use of “walking ability (6MWT)” rather than alternating between “walking” and “gait.”
• Consider adding a simple summary table of GAS goals with selection frequency and attainment rates across cycles.
• Language: small refinements (e.g., “Relief of spasms was the most consistently achieved goal, reached in 79.6% of cycles”).
• Funding: specify whether Ipsen Pharma had any role in study design, data analysis, or manuscript preparation.

Conclusion
In summary, this is a valuable and timely contribution. Addressing the points above will not only strengthen the methodological transparency of the study but also enhance its interpretative depth and clinical impact. I recommend major revision, with confidence that the abstract can be significance

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