Review Reports - Chronological Rehabilitation Treatment Varying by Stage for Constructive Disability

Round 1

Reviewer 1 Report

This article presents a case study where a glioblastoma patient with a parietal lobe disability undergoes a constructive function-based rehabilitation protocol to aid in the improvement of activities of daily living. There is relatively little published work on this type of constructive disability and rehabilitation methods. Therefore, this paper does present a problem and solution of high general interest to the rehabilitation and disability fields.

INTRODUCTION - While there are relatively few journal articles on the subject, there are more than the handful presented by the authors. A deeper dive is needed in the Introduction. The introduction should be split into a few sections: 1) overview of the definition of a functional disability that can benefit from constructive rehabilitation; 2) examples of previous rehabilitation protocols and their general make-up; 3) examples of medical causes of constructive disability, including acquired or congenital, that result in the type of disability discussed/presented; 4) overview of the specific patient case study (already written by the authors)

METHODS - more context for the general rehabilitation framework and the personalized framework for this patient is needed in the Methods. It would help if the authors provided a bullet list of the main goals and tasks for this patient's rehabilitation protocol before discussing them in detail.

RESULTS - The rehabilitation protocol method is innovative. However, it needs to be better generalized and a quantitative framework provided or at least a quantitative assessment of the patient at each stage of the protocol. For example, it is mentioned that the patient was timed in the shirt folding task, but no do data is provided to measure improvement over time. Another example would be the percentage of incorrectly folded left-side items at each stage, etc. Some form of quantitative results presented in tabular form or in a figure would greatly enhance the value and merit of the work.

DISCUSSION - The discussion needs divided into sections as well and material added: 1) impact of constructive disability on daily living; 2) summary of how the protocol presented could be generalized to other causes of constructive disability; 3) guidelines outcome measures that others who use the protocol can use as goals (this is where the quantitative data from the results would help, such as a percent increase in function from baseline at each stage); 4) how can the protocol potentially be adapted or personalized for nuanced differences in constructive functional disability; 5) limitations and future directions as it relates the development of a multi-stage constructive rehabilitation protocol.

Moderate English language editing is needed throughout. There are several run-on sentences or sentences missing either a subject or verb.

Author Response

Revewer1

Response: Thank you for your review, and thank you very much for your constructive opinion.

Response: Thank you for your advice. The text in the Introduction was revised, and additional literature on constructive disorders was added.

““Constructive apraxia” is a condition in which the spatial form of a constructed object is impaired. The term ”constructive disability” is used because constructive apraxia is commonly complicated by cognitive impairment [1-3]. It is often overlooked by patients or medical staff. [4]. Constructive disability occurs with damage to either the left or right hemisphere; right hemisphere lesions are often accompanied by visuospatial processing deficits [5, 6, 22, 23]. There are many cases in which rehabilitation treatment shows limited improvement due to associated deficits in spatial information processing and procedural action processes [7]. Rehabilitation therapy is considered to be effective for movement training that is closer to daily life. Evaluation tasks of constructive disability, such as drawing pictures and arranging building blocks, may not accurately reflect the difficulties experienced in daily activities [1]; thus, evaluation and training that align with the instrumental activities of daily living (IADL) of each individual are critical to ensure appropriate assessment and treatment.”

Kleist K. Kriegsverletzungen des Gehirns inihrer Bedeutung fur die Hirnlokalisation und Hirnpathologie.

In: Schjerning O eds Handbuch der Arztlichen Erfahrung im Weltkriege, 4, Leipzig,Berlin, Germany, 1934.

Piercy, M.; Hecaen, H.; De, Ajuriaguerra. Constructional apraxia associated with unilateral cerebral lesions-left and right sided cases compared. Brain 1960, 83, 225-242.

Response: There is no established method of rehabilitation for constructive disorders, and only direct therapeutic interventions are generally performed. We added a description of each intervention method.

“Direct therapeutic intervention is a treatment that stimulates and activates impaired function by repetitive practice of the impaired function or ability, and it has been reported that the functional improvement effect of repetitive motion is related to the regeneration and sprouting of neuronal axons. Direct therapeutic intervention is one of the most common types of rehabilitation for constructive impairment.

Compensatory interventions also utilize other functions or factors to achieve the impaired function or ability. Compensatory interventions are reported to reorganize the internal structure of nerve tissue by substituting other remaining healthy functions and combining impaired function with residual function. In addition, compensatory treatments are used to compensate for impaired functions and abilities using external assistance. Further, we aim to promote spatial analysis and integration with various sensory inputs [7].

IADL training consists of setting-based therapeutic interventions. IADL training is aimed at enhancing adaptive behavior in daily life and preventing and reducing problem behav-iors. Previous reports have demonstrated that improvement can be observed through a systematic step-by-step approach based on the patient's specific functionality and abilities [4].”

Response: Thank you for pointing this out. The time to fold the shirt and the degree of completion are semi-quantified and are shown over time. We also fixed the figure.

“In therapeutic intervention, methods of adding verbalization and clues to construction tasks have been reported, but none have been definitively established, and treatment methods differ depending on the technician in charge. In addition, there are many types of training, such as drawing pictures and arranging building blocks, and IADL training is rare.

We report a case in which a customized stage-based occupational therapy intervention was effective for a patient with progressive constructive disability. The patient received direct training and replacement therapy in the early stages and transitioned to instrumental activities of daily living training in the later stages. Such customized progressive occupational therapy was able to achieve substantial functional improvement even in patients with progressive cognitive and physical impairments due to structural impairment.”

Response: We modified the discussion to be divided into sections. Regarding interventions, we added a discussion of this case.

“Direct therapeutic intervention is a bottom-up approach. A bottom-up approach focuses on identifying the underlying causes of configuration disorders through individualized analysis and delivering targeted interventions. This approach is often chosen when intellectual capacity is declining. In this case, it was introduced at an early stage and had the effect of improving the speed of folding clothes. Conversely, compensatory intervention is a top-down approach, requires a broader perspective and insight, and relies on intact intellectual capacity to solve compositional problems, leading to improved folding accuracy. This approach is selected based on the individual's specific needs and abilities[14,15].

In this case, the introduction of compensatory training accelerated the improvement, but environmental adjustment from the beginning seems to have been a major factor.”

Moderate English language editing is needed throughout. There are several run-on sentences or sentences missing either a subject or verb.

Response: We had the English proofread by a native speaker again.

Author Response File: Author Response.docx

Reviewer 2 Report

The article is quite interesting, and deals with an important topic. The article should be revised before publication.

The introduction is too short and not explained in a comprehensive way "constructive disability" which can lead to confusion about the pathology. I recommend extending the introduction and increasing the number of bibliographic sources

Line 41 explain why T2 (transverse relaxation time) image acquisition is used in radio imaging diagnosis. Use this aricle PMC8086713

It would be preferable to mention what support medication the patient had during the four phases and if he did coordination exercises, balance exercises, etc.

The English language requires moderate editing

Author Response

The article is quite interesting, and deals with an important topic. The article should be revised before publication.

Response: Thank you for your review. Thank you very much for your constructive opinion.

Response: We have added an explanation about configuration failure in the Introduction.

Line 41 explain why T2 (transverse relaxation time) image acquisition is used in radio imaging diagnosis. Use this aricle PMC8086713

Response: Thank you for pointing us to the literature. We referred to it.

It would be preferable to mention what support medication the patient had during the four phases and if he did coordination exercises, balance exercises, etc.

Response: We have added information about other treatments.

Reviewer 3 Report

Thank you for the opportunity to review this work. However, the manuscript still has the following problems worthy of attention, through the improvement of these problems can better improve the quality of the manuscript.

Abstract:

The abstract should be coherent and flow logically from one idea to the next. Adding transition words/phrases to link sentences and parallel sentence structure may help. For example, "Constructive disability poses significant challenges...However, these manifestations are often overlooked...To address these disabilities, customized rehabilitation is necessary across disease stages."

The abstract should have a clear and concise thesis statement or objective. The current version is rather vague. Specifying the focus or goal of the rehabilitation case report and how it aims to address the stated challenges may strengthen the abstract. For example, "This case report demonstrates how customized, stage-based occupational therapy interventions can effectively rehabilitate patients with progressive constructive disability."

Brevity is key in an abstract. Removing unnecessary words and repetition may help condense the abstract. For example, "impediment, impacting" in the first sentence can be reduced to "impeding". "The overall manifestation...it is generally overlooked" can be rephrased as "These disabilities are often overlooked".

The abstract mentions different rehabilitation therapies but lacks specific details about the techniques or interventions used for the patient. Adding a sentence briefly describing the occupational therapy interventions at different disease stages may provide a better sense of how treatment was customized. For example, "The patient underwent direct training and compensatory therapy in early stages, progressed to instrumental activities of daily living training in later stages."

The conclusion is rather abrupt. Adding a sentence to briefly summarize the key outcomes or significance of this case report for clinical practice may strengthen the conclusion. For example, "This case demonstrates how such customized, progressive occupational therapy can achieve substantial functional improvements even for patients with advancing cognitive and physical impairments from constructive disability."

1 Introduction

The introduction is too short and lacks a clear thesis statement or main focus. It should be expanded to at least 5-6 sentences to give the reader a better sense of the scope and key arguments. A clear thesis statement should be added at the end of the introduction.

The first sentence is too long and confusing. It should be broken down into two simpler sentences for better readability and coherence. The terms like "constructive disability" and "concomitant apraxia" should be explained briefly for readers not familiar with them.

The second sentence mentions "cognitive impairment" but it is not very specific. The particular cognitive functions that are impaired in this condition should be specified. Some examples or explanations will help strengthen this statement.

The third sentence also makes a vague statement about "associated deficits in spatial information processing and procedural action processes". These deficits should be elaborated with more details and examples.

The last sentence proposes that IADL-based assessments may be more useful but does not give a convincing explanation for why they would be better. The limitations of existing evaluations mentioned in the previous sentence should be explained more thoroughly to build a case for IADL-based assessments.

Some additional details about the scope, aims and significance of the study should be added to strengthen the introduction. The key research questions or hypotheses should also be stated clearly.

2 Case Presentation

The case presentation section lacks a clear organisation and structure.

The initial paragraphs in the Case History provide good details about the patient's background and diagnosis but the details about the surgery and treatment are lacking. More specifics about the surgical procedure, post-surgical treatment and prognosis should be added.

The details under "Initial Evaluation" and "Final Evaluation" seem incomplete. Additional specifics about the tests, scores, imaging findings and their implications should be provided to give readers a better sense of the patient's condition and progress.

Under "Intervention", the plan is described in very general terms. More details about the specific occupational therapy techniques, activities, tools and materials used should be provided. The intervention process is described but not in a very coherent manner. Using the suggested headings and reorganising details under each phase chronologically may improve readability.

Visuals such as tables, graphs and images are helpful for case presentations but are lacking here. Visuals illustrating the patient's test scores, brain scans, rehabilitation activities etc. at different time points would effectively complement the details in text.

As with the introduction, a wider range of academic references should be cited here, especially when describing the patient's condition, evaluation tools, intervention techniques and expected outcomes. This helps substantiate the choices and claims in the case presentation.

3 Discussion and Conclusion

The discussion lacks a clear focus and logical flow of ideas. It would benefit from having an outline with headings and subheadings to organise the key points around a central topic or argument. For example, headings like "Impact of Visuospatial Deficits", "Evaluation of Constructive Disability", "Rehabilitation Approaches and Techniques" may help.

The first two paragraphs provide a good overview of constructive disability and its impacts but lack critical analysis. Relating the general points to the specific patient case and citing more research evidence would strengthen the discussion. Some analysis of how the patient's condition and outcomes align with or differ from those in other studies may be insightful.

The sections on "Rehabilitation treatment for constructive disability" and "Methods to guide patients" describe various techniques in a rather detached, theoretical manner without clearly relating them to the patient's treatment. Discussing how and why specific techniques were applied for this patient, their effectiveness and lessons learned would make this discussion more engaging and meaningful.

Some discussion of the challenges encountered, limitations of the rehabilitation program and recommendations for future research or practice may provide a balanced perspective to the discussion. For example, discussing ways to improve treatment intensity or effectiveness for patients with similar conditions.

The conclusion is too abrupt and repetitive. It should tie together the main points around the central topic or argument to highlight key takeaways for readers. Discussing the significance of this case for clinical practice or future research in more depth may make for a stronger conclusion.

As with the other sections, a wider range of research references should be cited, especially when describing general points or established theories. This helps to substantiate the discussion and indicates a thorough review of relevant literature. References should also be cited when relating the case details or outcomes to those of other studies.

Overall, the language quality in the manuscript content can be improved for clarity, conciseness and coherence. Here are some specific suggestions:

Complex sentences with multiple clauses should be simplified by splitting them into shorter sentences. This enhances readability and comprehension. For example, the first sentence of the introduction can be revised as:

"Constructive disability commonly occurs with cognitive impairment. It is characterized by impaired spatial organization and often overlooked by patients or medical staff."

Remove unnecessary words and repetition. For example, in the abstract, "impediment, impacting" can be reduced to "impeding". Repetition of "constructive disability" and "constructive disorders" should be avoided by using the terms consistently throughout.

Transition words and parallel sentence structure should be used to enhance coherence and flow. At present, ideas between sentences seem disconnected. Using words like "furthermore", "moreover", " however", " thus" and "as a result" can help link sentences. Parallel structure can be achieved by starting sentences with the same subject or pattern.

In places, the language seems rather informal and conversational. An objective, formal and academic tone is needed for manuscripts. For example, in the intervention process, "we introduced the patient to initially begin to sit on the knees..." may be rephrased as "The initial intervention focused on having the patient practice sitting, then progressing to...".

Transitional phrases are needed to link paragraphs and sections. For example, at the beginning of the Discussion, a sentence like "Based on the evaluations and intervention outcomes observed in this case, several key points warrant discussion." helps orientate the reader to the scope of the upcoming section.

Author Response

Response: Thank you for correcting these details. While we may not have responded to all comments, we have corrected the manuscript accordingly.

Abstract:

Response: We have rewritten the abstract. Thank you very much for your kind support.

“Constructive disability poses significant challenges. However, such manifestations are often overlooked. To address these disabilities, customized rehabilitation is necessary across disease stages. This case report demonstrates how customized, stage-based occupational therapy interventions can effectively rehabilitate patients with progressive constructive disability. Herein, a 33-year old female patient with progressive constructive disability underwent direct training and compensatory therapy in early stages and progressed to instrumental activities of daily living training in later stages. This case demonstrates how such customized, progressive occupational therapy can achieve substantial functional improvements even for patients with advancing cognitive and physical impairments from constructive disability. ”

1 Introduction

Some additional details about the scope, aims and significance of the study should be added to strengthen the introduction. The key research questions or hypotheses should also be stated clearly.

Response: We have added some sentences to clarify the argument and focus of the paper.

““Constructive apraxia” is a condition in which the spatial form of a constructed object is impaired. The term ”constructive disability” is used because constructive apraxia is commonly complicated by cognitive impairment [1-3]. It is often overlooked by patients or medical staff. [4]. Constructive disability occurs with damage to either the left or right hemisphere; right hemisphere lesions are often accompanied by visuospatial processing deficits [5, 6]. There are many cases in which rehabilitation treatment shows limited improvement due to associated deficits in spatial information processing and procedural action processes [7]. Rehabilitation therapy is considered to be effective for movement training that is closer to daily life. Evaluation tasks of constructive disability, such as drawing pictures and arranging building blocks, may not accurately reflect the difficulties experienced in daily activities [1]; thus, evaluation and training that align with the instrumental activities of daily living (IADL) of each individual are critical to ensure appropriate assessment and treatment.”

2 Case Presentation

The case presentation section lacks a clear organisation and structure.

Response: We have added the patient's background and the treatment and surgical methods.

Response: We have added the number of seconds it took to fold the clothes, and the degree of shaping in Figure 3.

Response: We have added citations and detailed descriptions of intervention methods.

3 Discussion and Conclusion

Response: We have added some subheadings to further clarify the discussion section.

Response: Thank you for your advice. In the first paragraph, we emphasized the most important points of this case report. “In therapeutic intervention, methods of adding verbalization and clues to construction tasks have been reported, but none have been definitively established, and treatment methods differ depending on the technician in charge. In addition, there are many types of training, such as drawing pictures and arranging building blocks, and IADL training is rare.

Response: Thank you for pointing out. We have revised the discussion text and added limitations.

Response: Thank you for pointing this out. We have removed the abrupt conclusion. It has been revised to connect to the main points of the topic and discussion and to emphasize the important points for the reader.　 “Direct therapeutic intervention is a bottom-up approach. A bottom-up approach focuses on identifying the underlying causes of configuration disorders through individualized analysis and delivering targeted interventions. This approach is often chosen when intellectual capacity is declining. In this case, it was introduced at an early stage and had the effect of improving the speed of folding clothes. Conversely, compensatory intervention is a top-down approach, requires a broader perspective and insight, and relies on intact intellectual capacity to solve compositional problems, leading to improved folding accuracy. This approach is selected based on the individual's specific needs and abilities[14,15].

In this case, the introduction of compensatory training accelerated the improvement, but environmental adjustment from the beginning seems to have been a major factor.”

Response: We have cited references to discuss the results of this case. However, due to the small number of papers on constructive disorders, there were limits to the discussion.

Comments on the Quality of English Language

Overall, the language quality in the manuscript content can be improved for clarity, conciseness and coherence. Here are some specific suggestions: Complex sentences with multiple clauses should be simplified by splitting them into shorter sentences. This enhances readability and comprehension. For example, the first sentence of the introduction can be revised as:

"Constructive disability commonly occurs with cognitive impairment. It is characterized by impaired spatial organization and often overlooked by patients or medical staff."

Response: Thank you for teaching us about sentence structure. This has been corrected, and the manuscript has undergone English proofreading by native speakers.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The authors have made substantive revisions that have greatly improved the paper. There are some minor formatting errors that will need addressed in the proof stage. However, the technical deficiencies have largely been remedied in the latest revision.

English has improved in the revision. Only minor errors remain.

Reviewer 3 Report

None