Dear Dr. Reddy,

Editorial Assessment:

This manuscript focuses on a clinically relevant and globally important issue - the effect of different levels of physical activity (PA) in the functional recovery and quality of life (QoL) and psychological change of people with musculoskeletal disorders undergoing physiotherapy. The paper is well written, well organized, and provides suitable statistical analyses. It provides methodological rigor in a number of ways, including the use of validated outcome measures (PSFS, SF-36, HADS) and the use of multivariable modeling with moderator analysis.

However, there are a number of substantive issues to consider in terms of clarity of study design, clarity of reporting methodology and transparency of data, statistical validity and consistency across sections. These issues must be deal with before the manuscript can be considered for publication. Some weaknesses are associated with the overinterpretation of cross-sectional results, inconsistent reporting of the results of analyses and unclear coding of variables.

With overtaking, this manuscript is capable of providing a useful contribution.

Major Comments (Require major revision)

1. Study Design Limitations Are Under Reported

This is a cross-sectional study, but in the manuscript, there is the repeated use of causal or quasi-causal terms (e.g. "physical activity contributed to recovery", improved outcomes", "dose-response relationship.

Cross-sectional data is unable to find direction or impact, only association.

Required:

Unique and discriminate to study claims: - “Server Finding”: - Theme of interest: - Major findings: - Claim: Due to the study, it is considered that there are some of the following ideas. Cloud or Version Cloud” Unique to the Studies of Claims: build Reset throughout the Abstract, Results, and Discussion and Conclusion of some version and association, the ideas of claim chain not cause.

Looking more specifically at studies of definitely carcinogenic substances, this would be a relevant consideration: according to Takano, "It has to be made clear that 'dose--response' is observational and is not causal."

2. Physical Activity Grouping Is Not Described in Sufficient Detail

The manuscript says that the subjects were divided into low, moderate and high activity groups but:

Cutoff METs No MET cutoffs used by the study are provided.

•It is not clear if classification was based on WHO, IPAQ scoring guidelines or custom thresholds.

Some of the non-technical reasons for using the thresholds are lacking (e.g., rationale for thresholds and distribution of participants into groups is missing).

Required:

Include exact MET values (i.e. "Low < X MET-min/week", etc.) and percentages of the participants in each category.

3. Potential Sampling Bias and Recruitment Procedure Should be Made Clear

Purposive sampling occurs in one tertiary treatment hospital may introduce several selection biases.

Concerns:

No explanation of how many patients were screened vs. enrolled.

Flow diagram (CONSORT-style suggested for PLOS ONE also for observational studies).

The report does not provide any detailed information on refusal rate or non-response characteristics.

Required:

Add participant flow information, explanation of sampling strategy limitations.

4. Multiple Variables Have No operational definitions

For example:

Baseline severity" is used in the model and never defined or described.

•"High socioeconomic status" does not have the exact classification criteria.

Medications used: Which medications? For what indications? How measured?

•Comorbidities - grouped as binary, but later described by authors as moderators.

Required:

Provide definitions and procedures for the measurement of these variables.

5. Statistical Analysis Section Overstates Rigor

Issues include:

o Claims regarding the multicollinearity checks without reporting on values of VIF.

Hypothesis Testing in Logistic Regression Model Fitting 1: Empirical Analysis and Interpretation Part III Model Testing 1. Model comparing F Statistics adjusted R2 for model Adjusted R2 per model 2. Residual versus Fitted 3. Effect of Variance 4. Residual vs. Fitted: Adding Polynomial basis & Interaction of two variables 5. Residual vs Fitted 6. Significance vs. Random Effects 7. Effect of Variance Logistic Regression Model Fitting Part III Model Testing 1.

Model parameters are wanting, particularly for exact models whereas interaction terms are described for moderation models.

•Report of incomplete (missing means, SD, post-hoc p-values and confidence intervals) for AN/ANCOVA.

Required:

Provide complete statistical reporting using PLOS ONE and APA guidelines.

6. Figures and Tables Incomplete Correspondence with the Narrative

Examples:

Table 1 reports on many of the variables that are not included in the main regression.

Of the above variables, the following are listed in Table 2 as not elaborated on as a priori model in methods:

Figures are mentioned in the text but not clearly described and/or labelled in the manuscript

Required:

Ensure consistency between:

Methods-> Statistical Analysis -> Tables-> Results.

7. Overreliance on Self Report Measures

The study acknowledges this limitation, but there is no discussion of its full implications, in particular:

•Social desirability bias

Overprediction of MET min in IPAQ-SF

•Recall bias

Methods: - Possibility that poor psychological status decreases reporting of physical activity

Required:

Strengthen the limitations section and its meaning for interpretation;

8. Citations Need Reviewing for Accuracy and Relevance

Several citations are not used to support the claims in the text. Examples:

Some references refer to surgical recovery, frailty or a cancer population - less relevant about physiotherapy to musculoskeletal disorders.

•Some are seemingly out of step with statements (e.g. a citation on sodium-glucose inhibitor prescriptions to support SES effects).

Required:

Review and correct references to help ensure they are supporting the particular statements.

Moderate/Structural Issues

9. The Introduction is Too Long and Repetitive

Several paragraphs repeat similar points of background information about the benefits of physical activity.

Suggestion: Fewer to sentence - 3-4 short, connected paragraphs.

10. Results Section Needs to be Clearer

PLOS ONE is fairly lenient when it comes to p values lacking effect sizes.

No indication whether tests for assumptions of linear regression (normality, homoscedasticity) were calculated.

Required: Input for assumption checks, important effect size measures

11. Wording Throughout Suggests Generalization Across Sample

Claims which seem to generalize findings to more general clinical populations should be moderated.

12. Ethical Approval Statement Should Make Clear Prospective or Retrospective Recruitment

This is required in PLOS ONE.

Minor Issues

13. Minor Language Issues

The manuscript is generally well written but includes:

•Repetition ("well-documented" is repeated too often)

Excessive use of the phrase "these findings highlight"

•Occasional grammar problems (e.g. article, inconsistent tense)

A polish pass of the language is recommended.

14. Formatting Issues

Example: For example, "Click here to access/download" should be replaced with nicer text.

Documentary elements must adhere to the structure of PLOS ONE for: - Caption to figure.

Include the following in your answer in the rubric: "please show consistency in reporting decimals" 2 vs. 3 decimal places

15. Data Availability

For this case, the DOI for Zenodo is provided. Confirm the completeness of data sets as well as clarity of codebook

Recommendation

Decision: MAJOR REVISION

The manuscript discusses an important topic and presents appropriate standardized tools; however, significant revision is necessary to make certain:

Appropriate interpretation of cross-sectional data

Transparency in reporting method and statistical procedures

Definitive explanations of variables

Improved coherence between sections

Limited and discussed biases

If the above points are taken seriously by the authors, the manuscript will certainly be much stronger and will be suitable for publication.

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We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Sidiq, PhD Pain Sciences Physiotherapy

Academic Editor

PLOS One

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Deanship of Research and Graduate Studies, King Khalid University, grant number: RGP.2/22/46.

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Deanship of Research and Graduate Studies, King Khalid University, grant number: RGP.2/22/46.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Dear author, I congratulate you on your article. Although a comprehensive statistical analysis has been conducted, I would like to express some concerns.

Please cite the similar literature you mentioned in the sample analysis.

Please don't explain statistical analysis methods in the discussion. Explain directly the reason for your findings. There is little discussion of the findings in this regard. Explain further how this study contributes to future studies. Also, include a comment on how the duration of comorbidities in the regression model affected the model. In the abstract, indicate how you measured functional recovery.

Reviewer #2: Thank you for your hard work and insightful research; however, there is a need for correction, and more clarity to be more useful and easier to use in the clinicals and more useful for researchers to understand and use as reference.

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Reviewer #1: No

Reviewer #2: Yes: Paiwand Mamand

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Attachments

Attachment

Submitted filename: PLOS one review points.docx

<p>Association Between Physical Activity Levels and Functional Recovery, Quality of Life, and Psychological Well-Being in Patients Undergoing Physiotherapy for Musculoskeletal Disorders: A Cross-Sectional Study.

PONE-D-25-55451R1

Dear Dr. Reddy,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. I am satisfied with the revision provided by the authors.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter, and your manuscript will be scheduled for publication.

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Kind regards,

Mohammad Sidiq, PhD Pain Sciences Physiotherapy

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: