-->PONE-D-25-27347-->-->Deconstructed Tai Chi Step Training Combined with Conventional Rehabilitation Significantly Improves Lower Limb Function in Brunnstrom Stage III Stroke Patients: A Randomized Controlled Trial-->-->PLOS ONE

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Aynollah Naderi

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Author,

The study addresses an important and innovative area of post-stroke rehabilitation by exploring a “deconstructed Tai Chi” protocol specifically tailored to patients at Brunnstrom Stage III. The focus on stage-specific intervention is clinically relevant and offers a potentially low-cost, culturally meaningful approach to neurorehabilitation. The quantitative findings are promising and indicate measurable improvements in lower limb motor function. However, several sections require substantial clarification and enhancement to strengthen methodological rigor, theoretical grounding, and interpretive depth.

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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?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Here is a list of specific comments. Note: line and page numbering in reviews and comments is based on ruler applied in Editorial Manager-generated PDF.

1. Page 5, line 94: I suggest adding a subsection to describe the outcomes of interest. If the sentences in lines 203–209 described the outcomes, creating a subsection would satisfy this comment.

2. Page 6, lines 110–111: I suggest stating when the participant in the E group discontinued the intervention and when the participant in the C group lost to follow-up.

3. Page 6, lines 118–119: The sample size was calculated based on a continuous outcome. In this manuscript, five outcomes were assessed. I suggest including a potential inflated type-1 error as a limitation in the Discussion section.

4. Page 7, lines 133–136: The exclusion was post-randomization and made the analysis per-protocol.

5. Page 11, lines 203–209: Assuming these were the outcomes, I suggest including the timing when the outcomes were assessed.

6. Page 11, line 210: I suggest stating the primary population of analysis (e.g., intention-to-treat, per-protocol, etc.)

7. Page 11, lines 215–217: I suggest revising the sentence to clarify that both t-test and Mann-Whitney U test are for continuous variable but one is parametric (t-test) and the other is non-parametric (Mann-Whitney U test).

8. Page 11, lines 215–216: I suggest clarifying if the between-group comparisons were based on the pre-and-post change or post-intervention measurements.

9. Page 12, Table 1: Baseline characteristics were expected to be balanced due to the randomization. I suggest removing the Statistic and p-value columns. If needed, I suggest reporting standardized mean differences.

10. Page 13, lines 238–240: I suggest not reporting the p-values if they comparisons were not the primary objective of the study. Reporting means and 95% confidence intervals would be sufficient. Please apply this comment throughout the manuscript.

11. Page 14, line 245: A binary outcome was not considered when calculating the required sample size.

Reviewer #2: Dear Author,

You have made great effort in crafting a well written manuscript that aligns with the subject area.

In order to enhance the quality and validity of your work, I recommend you ensuring that all references are thoroughly incorporated and updated to reflect the latest developments in the field.

This will strengthen the foundation of your paper and provide readers with a comprehensive understanding of the topic. I encourage you to review and update your references accordingly.

Well done

Reviewer #3: Dear Authors,

I have completed my review of your manuscript and found it to be a well-conducted and valuable study. The research addresses a pertinent clinical question with a robust methodological approach.

Reviewer #4: Overall Evaluation

The topic is clinically relevant, addressing a significant gap in stage-specific post-stroke rehabilitation. The findings are promising and supported by quantitative evidence. However, several aspects, particularly in methodological transparency, discussion depth, and theoretical contextualization require clarification or strengthening to enhance scientific rigor and reproducibility.

Comments

The concept of “deconstructed Tai Chi” tailored to Brunnstrom Stage III is original and aligns with growing interest in culturally adapted, low-cost rehabilitation methods. However, the degree of novelty should be clarified in relation to prior studies on simplified Tai Chi interventions in stroke recovery (e.g., Li et al., 2018; Zou et al., 2019).

The introduction could better distinguish this protocol from prior modified Tai Chi programs by emphasizing how joint isolation targeting extensor synergy specifically meets the neurophysiological needs of Stage III patients. Add 2–3 sentences in the introduction explaining how deconstructed Tai Chi differs in biomechanical intent and progression from previously reported Tai Chi-based interventions for post-stroke recovery.

The introduction currently introduces stroke rehabilitation but lacks sufficient pathophysiological context linking vascular vulnerability and metabolic risk factors to the need for rehabilitative intervention. Add below phrase with recent literature support as shown to strengthens the scientific justification for this study.

“Previous research has emphasized that cerebrovascular fragility and metabolic risk factors, particularly obesity, play a pivotal role in precipitating fatal brain hemorrhages even in individuals without prior clinical symptoms [Sheikh et al., 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11875705/ ]. These findings underscore the importance of preventive and restorative strategies aimed at enhancing neurovascular stability and functional resilience, which are core objectives guiding rehabilitation approaches in stroke and related neurological disorders.”

Methodology

Describe how random allocation was performed (e.g., sealed envelopes, computer-generated sequence) and who managed allocation concealment.

While blinding therapists is difficult, please elaborate on how assessor blinding integrity was verified.

Clarify the reference study used for the effect size (d = 1.2). A citation and calculation example would strengthen credibility.

Report dropout reasons (if any) and whether intention-to-treat (ITT) analysis was conducted.

Include a methodological clarification paragraph specifying randomization control, adherence verification, and bias minimization.

Results

The clinical relevance of the between-group difference in FMA-LE (+5.6 vs. +1.8) should be interpreted in the context of minimal clinically important difference (MCID) for post-stroke lower limb function. Additionally, the use of multiple parametric tests across ROM and FMA variables without correction (e.g., Bonferroni) increases the risk of Type I error. Discuss the clinical meaningfulness of the effect size and specify whether adjustments for multiple comparisons were applied.

Discussion

The discussion appropriately highlights neuroplastic and proprioceptive mechanisms; however, it misses deeper integration with motor control theory and neurorehabilitation frameworks.

The section could benefit from citing functional imaging or EMG-based Tai Chi studies to support claims about cortical reorganization.

The discussion currently emphasizes clinical rehabilitation outcomes but misses integration with recent multidisciplinary evidence linking physical activity to neurobiological recovery mechanisms. Add below phrase to strengthen holistic model where physical therapy not only restores motor function but also enhances neuroplasticity, emotional resilience, and overall brain health.

“Emerging evidence has demonstrated that structured physical therapy and exercise interventions can positively modulate neurobiological pathways, promoting neurogenesis, mood stabilization, and functional recovery in neurological disorders [Nasif et al., 2025, https://doi.org/10.31579/2578-8868/359 ]. These findings highlight the broader rehabilitative potential of physical engagement in restoring neurovascular and psychosocial integrity following brain injury or hemorrhage, thereby supporting integrated rehabilitation frameworks for stroke survivors.”

Limitations and Future Scope

Include potential gender imbalance or age-related variability in recovery. Discuss cultural transferability — can this Tai Chi-based model be applied outside East Asia? Consider proposing longitudinal follow-up or home-based adaptation as a research priority. Add one paragraph proposing multicenter validation and wearable-based outcome tracking (e.g., kinematic or EMG-based monitoring) to enhance reproducibility and global applicability.

Reviewer #5: L29–35 (Abstract): Avoid repetitive “significantly improves” phrasing; maintain scientific neutrality.

L85–93 (Introduction): Add explicit hypotheses.

L118–124: Provide numerical justification for sample size calculation.

L210–220: Include CI and η² effect sizes.

L287–320: In Discussion, cite neuroplasticity mechanisms with updated evidence (e.g., Neurorehabilitation and Neural Repair, 2024).

Figures: Label all axes, specify “mean ± SD”, and mark significant differences properly (p<0.05, p<0.01).

Language: Avoid promotional expressions such as “highly recommended for clinical incorporation.” Instead, use “suggests potential for inclusion in clinical practice pending larger trials.”

Clarify randomization and concealment methods.

Include or re-analyze data with repeated-measures ANOVA or mixed models.

Report 95% CI for all major results.

Explicitly state hypotheses and improve Discussion balance.

Update literature (2024–2025) and moderate the tone of conclusions.

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Reviewer #1: No

Reviewer #2: Yes: Ebenezer Ad Adams

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

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Attachments

Attachment

Submitted filename: Comments.docx

DEffects of Deconstructed Tai Chi Step Training Combined with Conventional Rehabilitation on Lower Limb Function in Brunnstrom Stage III Stroke Patients: A Randomized Controlled Trial

PONE-D-25-27347R1

Dear Dr. Yindong Li,

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.

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Kind regards,

Aynollah Naderi

Academic Editor

PLOS One

Additional Editor Comments (optional):

Your comprehensive, transparent, and well-structured responses to all points raised by the reviewers and the editor demonstrate a clear commitment to strengthening methodological rigor, reporting transparency, and balanced scientific interpretation. The implemented revisions—including the addition of a dedicated outcomes subsection, reporting of 95% confidence intervals and effect sizes, appropriate use of repeated-measures ANOVA, clarification of randomization and assessor blinding procedures, removal of p-values from the baseline characteristics table, and moderation of the manuscript’s tone—are fully aligned with CONSORT guidelines and PLOS ONE requirements, and have effectively resolved the reviewers’ primary concerns. Provided that the authors finalize the data availability statement, validate the corresponding author’s ORCID iD, and ensure strict adherence to the journal’s formatting instructions prior to final submission, the manuscript is scientifically and methodologically sound and ready for acceptance.

Reviewers' comments: