Targeted Physical Rehabilitation for Physical Function Decline in Patients with Schizophrenia: A Narrative Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Introduction:

• Line 50-51: delete the repetition of the word "and".
• Paragraph lines 56–63 and 64–71: If I may offer a suggestion, it would be to reverse the order of these paragraphs. This might improve the flow of the argument.
• It is suggested that the literature review paragraphs (2.3.1 to 2.3.6) be incorporated directly into the introduction to reinforce the theoretical framework

Material and method:

• It seems that Figure 2 lacks precision:
  • Could you kindly provide the number of articles found in Web of Science?
  • Could you please clarify how many were retained at each stage of screening?
  • Could you kindly provide the number of individuals selected for each rehabilitation category?
• It seems that sections 3.1.1–3.1.3 largely repeat the methodology, which may be a good opportunity to consider merging or simplifying them.

Results and discission:

• It seems that paragraphs 3.1.1, 3.1.2, and 3.1.3 might be repeating the section on materials and methods.
• The summary tables (1, 2, 3) are useful, but it might be beneficial to consider incorporating comparative elements to further enhance their utility.
• It would be beneficial to consider a comparison with existing literature on the subject. This conceptual framework could be compared with models that have been published in the areas of geriatrics, neurology, or rehabilitative psychiatry.

Conclision:

• If the discussion is quite lengthy and repetitive, it might be beneficial to condense it in order to refocus on the key message.

Suggestion: To improve readability, it might be beneficial to consider including flowcharts that illustrate the cascade (ex: antipsychotics → side effects → functional consequences).

Author Response

Reviewer 1

According to the reviewer's suggestion, we have revised our manuscript as a review paper with the following sections: Abstract, Keywords, Introduction, Relevant Sections, Discussion, Conclusions and Future Directions. We sincerely appreciate the opportunity to revise our manuscript, now entitled: Targeted physical rehabilitation for physical function decline in patients with schizophrenia: review paper.

We are grateful to the reviewers for their insightful comments and constructive feedback, which have significantly improved the quality and clarity of our work. In response, we have carefully revised the text to reflect all comments provided. A point-by-point response is enclosed, outlining how each comment was addressed in the revised version. Revisions in the manuscript have been marked in red font, and specific changes referenced by section.

We believe these revisions have improved the quality and clinical relevance of the manuscript.

Thank you again for your time and thoughtful evaluation.

We look forward to your continued review.

 

Reviewer’s Comments and Suggestions for Authors

Reviewer 1

Introduction:

 

1. Line 50-51: delete the repetition of the word "and".

Response: Thank you very much for pointing out this error. We have revised it accordingly.

2. Paragraph lines 56–63 and 64–71: If I may offer a suggestion, it would be to reverse the order of these paragraphs. This might improve the flow of the argument.

Response: Thank you very much for your comment. We have revised it accordingly.

3. It is suggested that the literature review paragraphs (2.3.1 to 2.3.6) be incorporated directly into the introduction to reinforce the theoretical framework

Response: Thank you very much for your suggestion. We have incorporated the sections into the introduction.

 

Material and method:

1. It seems that Figure 2 lacks precision:

• Could you kindly provide the number of articles found in Web of Science?

Response: Thank you very much for your suggestion. The database used was PubMed only, and the citation was incorrect. Thank you for pointing this out.

• Could you please clarify how many were retained at each stage of screening?
• Could you kindly provide the number of individuals selected for each rehabilitation category?

Response: Thank you very much for your suggestion. Regarding the three points above, we updated Figure 2 to include the number of papers found and ultimately used for each category. The result is a clearer figure. Thank you very much.

 

• It seems that sections 3.1.1–3.1.3 largely repeat the methodology, which may be a good opportunity to consider merging or simplifying them.

Response: We have edited these, thank you so much.

Results and discussion:

• It seems that paragraphs 3.1.1, 3.1.2, and 3.1.3 might be repeating the section on materials and methods.

Response: We have edited these, thank you so much.

• The summary tables (1, 2, 3) are useful, but it might be beneficial to consider incorporating comparative elements to further enhance their utility.

Response: We have made a discussion based on table 1-3.

• It would be beneficial to consider a comparison with existing literature on the subject. This conceptual framework could be compared with models that have been published in the areas of geriatrics, neurology, or rehabilitative psychiatry.

 

Conclusion:

• If the discussion is quite lengthy and repetitive, it might be beneficial to condense it in order to refocus on the key message.

Suggestion: To improve readability, it might be beneficial to consider including flowcharts that illustrate the cascade (ex: antipsychotics → side effects → functional consequences).

Response: Thank you for your constructive feedback on our manuscript. We appreciate your suggestion to make the conclusion more concise and to use a visual aid to illustrate the core message. We agree that these revisions have significantly improved the clarity and impact of our paper.

In response to your comments, we have made the following key changes:

Addition of Visual Aids: In response to suggestions for visual aids, two new bullet points have been added to clarify different aspects of this framework.

In the Discussion (Section 5), a new section “5.4. Practical Application and Clinical Workflow” has been added. This section presents a flowchart that concretizes this framework as a step-by-step clinical workflow, illustrating how practitioners can evaluate, classify, and adjust rehabilitation plans.

 

In the Conclusion (Section 6), we added the chain of physical functional decline in schizophrenia. This directly addresses the suggestion to show sequential outcomes across the three domains.

 

Furthermore, we created a graphical abstract to visually illustrate these relationships.

We believe these changes directly address your insightful suggestions and have resulted in a stronger, more accessible manuscript. We thank you again for the opportunity to enhance our work.

Reviewer 2 Report

Comments and Suggestions for Authors

<General Summary>

This conceptual review proposes a rehabilitation framework for physical function decline in schizophrenia.  The authors searched PubMed/MEDLINE and Web of Science (Jan 2014–Jan 2025) and organize problems into three domains: antipsychotic-related motor dysfunction; dynapenia/sarcopenia/frailty (including sedentary behavior and dysphagia risk); and neuro-motor limitations (accelerated brain aging/disuse).  They advocate aerobic, resistance, balance, flexibility, dual-task, visual–vestibular work, and nutrition/OT inputs, emphasizing integration with psychiatric care.

<Major Issues>

The clinical problem is important and the narrative correctly links positive symptoms to impaired ADLs/avoidance, negative symptoms to reduced goal-directed activity, and underdiagnosed depression to worse function.  That said, the conceptual advance remains limited: the three domains largely re-aggregate established factors without articulating mechanism-to-intervention pathways that would yield testable, domain-specific prescriptions.  Strengthening novelty will require clearer causal links and decision rules that move beyond restating known contributors.

Methods are insufficiently transparent for a review that aims to guide practice.  The paper names two databases and a date window but does not report full search strings, inclusion/exclusion criteria, screening counts with reasons, or any study quality appraisal.  Figure 2 shows a large initial count [“PubMed (n = 34,632)”] but provides no downstream flow.  Data extraction is described only as “two physical therapists extracted general physical therapy treatments”, with no detail about independence, consensus, or forms.  As written, the methods are not auditable or reproducible.

The taxonomy is inconsistent across sections and figures.  The overview defines three main factors, yet the later classification lists four categories and duplicates antipsychotic-induced movement disorders across items 1 and 2.  This inconsistency makes it hard to map assessments and treatments to unique domains.  Please reconcile the framework into non-overlapping categories and redraw figures accordingly.

Actionability needs to improve.  The manuscript does cite schizophrenia-specific evidence on low physical activity/sedentary behavior and actigraphy-style objective activity, which is valuable; however, the recommendations remain generic (e.g., “utilize balance assessments,” broad aerobic/strength advice) without schizophrenia-specific screening, safety checks, contraindications, or FITT-style dosing and progression by illness stage, medication, or setting.  Converting principles into parameterized protocols, linked to validated outcomes (e.g., walking speed, ADL/IADL measures), would increase clinical utility.  The statement about higher Parkinson’s disease risk in people with mental illness <50 years also needs context (design, confounders, absolute risk) to avoid misinterpretation.

<Minor Issues>

The selection diagram should include counts at each stage, not only database totals.  These presentation issues distract from the content.  Please also audit source-to-claim alignment throughout the Results/Tables.  For example, “applied movement training” is attributed to reference [55]; ensure that [55] indeed supports applied movement training as used here, and add population/design annotations in tables to clarify transferability to schizophrenia.

Author Response

Reviewer 2

According to the reviewer's suggestion, we have revised our manuscript as a review paper with the following sections: Abstract, Keywords, Introduction, Relevant Sections, Discussion, Conclusions and Future Directions. We sincerely appreciate the opportunity to revise our manuscript, now entitled: Targeted physical rehabilitation for physical function decline in patients with schizophrenia: narrative review paper.

We are grateful to the reviewers for their insightful comments and constructive feedback, which have significantly improved the quality and clarity of our work. In response, we have carefully revised the text to reflect all comments provided. A point-by-point response is enclosed, outlining how each comment was addressed in the revised version. Revisions in the manuscript have been marked in red font, and specific changes referenced by section.

We believe these revisions have improved the quality and clinical relevance of the manuscript.

We look forward to your continued review.

 

Point-by-Point Response to Reviewer 2

Thank you again for your very thorough and critical review of our manuscript. We appreciate your valuable insights regarding the need for greater clarity, consistency, and clinical actionability. Your comments have been pivotal in guiding our substantial revision process.

As a foundational point, we would like to clarify that this manuscript is a Narrative Review intended to synthesize existing literature and propose a novel Conceptual Framework for clinical application, rather than a systematic review designed to address a single, precise research question. This clarification guides our response to the methodological comments below.

 

Major Issues Addressed

Conceptual Advance and Novelty (Mechanism-to-Intervention)

Reviewer Comment: That said, the conceptual advance remains limited: the three domains largely re-aggregate established factors without articulating mechanism-to-intervention pathways that would yield testable, domain-specific prescriptions. Strengthening novelty will require clearer causal links and decision rules that move beyond restating known contributors.

 

Response: We agree that a conceptual framework must articulate clear, testable links between mechanisms and interventions. We have significantly enhanced the novelty and clinical utility of the paper by shifting the focus from simply aggregating known factors to explicitly detailing the Mechanism-to-Intervention Pathway:

 

Practical Applications and Clinical Workflow: We developed and included a Clinical Workflow (Section 5.4, in Discussion), which serves as a decision-rule guide. This figure explicitly demonstrates how a clinician assesses a patient, categorizes their dysfunction into one of our three domains, and implements a precisely tailored, domain-specific intervention strategy.

 

Table Revision: We fully revised Tables 1-3 to explicitly articulate the Rationale & Key Interventions that are specific to the unique etiology in schizophrenia (e.g., dual-task training for cognitive-motor deficits).

 

Methods Transparency and Reproducibility

 

Reviewer Comment: Methods are insufficiently transparent for a review that aims to guide practice. The paper names two databases and a date window but does not report full search strings, inclusion/exclusion criteria, screening counts with reasons, or any study quality appraisal. ... As written, the methods are not auditable or reproducible.

 

Response: We recognize the need for transparency, even within a Narrative Review format. To enhance audibility without compromising the narrative focus of the paper:

Review Context: We have clarified the study as a Narrative Review to set appropriate expectations for the methodology.

 

Literature Inclusion Criteria: We revised Section 1.2.1 (Search Strategy) to explicitly list the criteria used to select literature relevant to the framework's development.

Search Scope: We have now included the major keywords and database search structure used for PubMed/MEDLINE.

 

Data Reliability: We explicitly state that the literature synthesis was performed by two authors independently, followed by consensus, to ensure reliability and minimize bias.

(Crucial Point on PRISMA): We respectfully confirm that we will not include a PRISMA-style flow diagram or full quantitative counting. The purpose of this review is the qualitative synthesis and conceptual integration of diverse evidence to build a framework, which falls outside the scope of a standard systematic review.

We have implemented a modified selection diagram (Figure 1 and 2) that illustrates the flow of literature and includes the initial database totals, addressing the presentation issue. As noted above, we respectfully decline the request for full quantitative counting in line with our narrative review scope.

 

The taxonomy is inconsistent across sections and figures.

 

Reviewer Comment: The taxonomy is inconsistent across sections and figures. The overview defines three main factors, yet the later classification lists four categories and duplicates antipsychotic-induced movement disorders across items 1 and 2. This inconsistency makes it hard to map assessments and treatments to unique domains. Please reconcile the framework into non-overlapping categories and redraw figures accordingly.

 

Response: We apologize for the initial inconsistency in the taxonomy. We have audited the entire manuscript to ensure absolute consistency:

Unified Taxonomy: The final framework strictly adheres to three non-overlapping domains throughout the entire manuscript (Abstract, Tables, Discussion, and Figures).

Figure Reconciliation: The text in Section 1.2.2 now clearly explains that the initial broad factors identified during the review were synthesized and aggregated into these three distinct domains to optimize clinical actionability.

 

Actionability needs to improve.

 

Reviewer Comment: Actionability needs to improve. ... the recommendations remain generic ... Converting principles into parameterized protocols, linked to validated outcomes (e.g., walking speed, ADL/IADL measures), would increase clinical utility.

 

Response: We have strengthened the clinical actionability by providing the specific details requested:

 

Addition of Visual Aids: In response to suggestions for visual aids, two new bullet points have been added to clarify different aspects of this framework.

In the Discussion (Section 5), a new section “5.4. Practical Application and Clinical Workflow” has been added. This section presents a flowchart that concretizes this framework as a step-by-step clinical workflow, illustrating how practitioners can evaluate, classify, and adjust rehabilitation plans.

 

In the Conclusion (Section 6), we added the chain of physical functional decline in schizophrenia. This directly addresses the suggestion to show sequential outcomes across the three domains.

 

Furthermore, we created a graphical abstract to visually illustrate these relationships.

 

We believe these changes directly address your insightful suggestions and have resulted in a stronger, more accessible manuscript. We thank you again for the opportunity to enhance our work.

 

Minor Issues Addressed

The selection diagram should include counts at each stage... Please also audit source-to-claim alignment...

 

Response: We completed the audit, confirming source-to-claim alignment and adding clarifying annotations where necessary in the text and tables to improve transferability.

Reviewer 3 Report

Comments and Suggestions for Authors

This study brings up a very relevant issue with regard to patients with schizophrenia where there is physical function decline with prolonged hospitalization.  I have a background as a clinician and have taken care of similar patients. Note that the manuscript is a conceptual study rather than an empirical investigation, i.e., no patients were directly assessed. I was a bit surprised at this, but such an approach is reasonable and valid in this complex field. Conceptual frameworks can play an important role in synthesizing existing evidence and guiding the design of more effective interventions, so that is the basis on which I read and evaluated this paper.

The authors propose a three-domain model of physical decline in schizophrenia, namely antipsychotic-related motor dysfunction, sarcopenia/frailty, and neuromotor limitations. They then outline tailored physical rehabilitation strategies aimed at maintaining independence and reducing early mortality. This is a very valid concern in schizophrenia care.

I thought the authors clearly structured their framework, linking physical decline in schizophrenia to both illness-related and treatment-related mechanisms. They proposed specific rehabilitation approaches (aerobic and resistance training, balance and flexibility interventions, swallowing therapy, nutritional support) that are supported by the literature and clinical traditions. There is emphasis on early and preventive intervention, multidisciplinary collaboration, and the integration of physical therapy into psychiatric care.

From my own experiences I found that a key limitation in this paper is the absence of cognitive rehabilitation in the framework. While the authors acknowledge that cognitive impairment contributes to sedentary behavior and functional decline, they do not discuss or incorporate cognitive rehabilitation strategies (of course, this is *not* the cognitive therapy of CBT, which on its own can be useful). Many such cognitive strategies have substantial evidence for improving attention, memory, executive function, and daily living outcomes in schizophrenia. Given the strong bidirectional relationship between cognition and physical functioning, omission of this domain leaves the framework incomplete. Perhaps the authors would consider including this more prominently in their rehabilitation strategy. I believe it could synergize with physical rehabilitation to improve patient outcomes.

Overall, I believe this is a valuable conceptual contribution, but it would be strengthened by addressing cognitive rehabilitation as part of a comprehensive framework.

 

Author Response

Reviewer 3

According to the reviewer's suggestion, we have revised our manuscript as a review paper with the following sections: Abstract, Keywords, Introduction, Relevant Sections, Discussion, Conclusions and Future Directions. We sincerely appreciate the opportunity to revise our manuscript, now entitled: Targeted physical rehabilitation for physical function decline in patients with schizophrenia: review paper.

We are grateful to the reviewers for their insightful comments and constructive feedback, which have significantly improved the quality and clarity of our work. In response, we have carefully revised the text to reflect all comments provided. A point-by-point response is enclosed, outlining how each comment was addressed in the revised version. Revisions in the manuscript have been marked in red font, and specific changes referenced by section.

We believe these revisions have improved the quality and clinical relevance of the manuscript. Thank you again for your time and thoughtful evaluation.

We look forward to your continued review.

 

Reviewer’s Comments and Suggestions for Authors

This study brings up a very relevant issue with regard to patients with schizophrenia where there is physical function decline with prolonged hospitalization.  I have a background as a clinician and have taken care of similar patients. Note that the manuscript is a conceptual study rather than an empirical investigation, i.e., no patients were directly assessed. I was a bit surprised at this, but such an approach is reasonable and valid in this complex field. Conceptual frameworks can play an important role in synthesizing existing evidence and guiding the design of more effective interventions, so that is the basis on which I read and evaluated this paper.

 

Response: Thank you for your clinical perspective on this review. We would like to present something that can be used in psychiatric care. We are grateful for your review of our paper.

 

The authors propose a three-domain model of physical decline in schizophrenia, namely antipsychotic-related motor dysfunction, sarcopenia/frailty, and neuromotor limitations. They then outline tailored physical rehabilitation strategies aimed at maintaining independence and reducing early mortality. This is a very valid concern in schizophrenia care. I thought the authors clearly structured their framework, linking physical decline in schizophrenia to both illness-related and treatment-related mechanisms. They proposed specific rehabilitation approaches (aerobic and resistance training, balance and flexibility interventions, swallowing therapy, nutritional support) that are supported by the literature and clinical traditions. There is emphasis on early and preventive intervention, multidisciplinary collaboration, and the integration of physical therapy into psychiatric care.

 

Response: Thank you for your comments, which are appropriate from clinical and academic perspectives. We are glad to know that our views align with clinical reality.

From my own experiences I found that a key limitation in this paper is the absence of cognitive rehabilitation in the framework. While the authors acknowledge that cognitive impairment contributes to sedentary behavior and functional decline, they do not discuss or incorporate cognitive rehabilitation strategies (of course, this is *not* the cognitive therapy of CBT, which on its own can be useful). Many such cognitive strategies have substantial evidence for improving attention, memory, executive function, and daily living outcomes in schizophrenia. Given the strong bidirectional relationship between cognition and physical functioning, omission of this domain leaves the framework incomplete. Perhaps the authors would consider including this more prominently in their rehabilitation strategy. I believe it could synergize with physical rehabilitation to improve patient outcomes. Overall, I believe this is a valuable conceptual contribution, but it would be strengthened by addressing cognitive rehabilitation as part of a comprehensive framework.

 

Response: Thank you for your constructive feedback on our manuscript. We sincerely appreciate your valuable insight that incorporating cognitive rehabilitation strategies would significantly strengthen our conceptual framework. We agree that the bidirectional relationship between cognitive and physical functioning is a crucial aspect of schizophrenia rehabilitation, and your suggestion has provided us with a vital opportunity to enhance the comprehensiveness and clinical utility of our review.

In response to your comments, we have revised our manuscript to more prominently feature cognitive rehabilitation. Specifically:

Expanded Discussion: We have integrated cognitive rehabilitation strategies into Section 4, now titled "Physical Rehabilitation for Neuro-Motor and Cognitive Deficits." This expanded discussion now clarifies how specific physical interventions, such as dual-task training and rhythmic exercises, directly target and improve core cognitive functions like attention and executive function.

Revised Framework Table: We have updated Table 3 to include a new row dedicated to "Cognitive-Motor Integration." This new section outlines the rationale, key interventions, and unique characteristics of this approach in schizophrenia, emphasizing its synergistic effect with physical rehabilitation.

We believe these revisions directly address your insightful suggestions by providing a more comprehensive and holistic view of rehabilitation in this population. We are confident that these changes have significantly strengthened the manuscript's contribution to the field.

Thank you again for your time and expertise.

 

 

Reviewer 4 Report

Comments and Suggestions for Authors

This manuscript attempts to provide a systematic way to help schizophrenia patients to recover physical activity to some extent by reviewing the existing literature. It also provides a comprehensive approach of physical rehabilitation for each motor-related dysfunction that the authors identified. However, the manuscript does not describe a guideline in clinical settings, how practitioners identify and categorize the motor dysfunctions in schizophrenia into three categories and design rehabilitation plans accordingly. The authors should address this issue.

 

A few small points:

 

• In both the abstract and the introduction, the authors started describing schizophrenia using Japan’s epidemiology data, which could lead readers to think that the study is based on Japan’s population, but the manuscript is not limited to Japan. So please incorporate worldwide epidemiology data.

 

• 1 seems oversimplified. The authors still need to describe what the method is in this manuscript.

 

• In Figure 1. The 2^nd textbox seems to contain the quote symbols “[]” from a non-English input method. Please change the symbols.

Author Response

Reviewer 4

According to the reviewer's suggestion, we have revised our manuscript as a review paper with the following sections: Abstract, Keywords, Introduction, Relevant Sections, Discussion, Conclusions and Future Directions. We sincerely appreciate the opportunity to revise our manuscript, now entitled: Targeted physical rehabilitation for physical function decline in patients with schizophrenia: review paper.

We are grateful to the reviewers for their insightful comments and constructive feedback, which have significantly improved the quality and clarity of our work. In response, we have carefully revised the text to reflect all comments provided. A point-by-point response is enclosed, outlining how each comment was addressed in the revised version. Revisions in the manuscript have been marked in red font, and specific changes referenced by section.

We believe these revisions have improved the quality and clinical relevance of the manuscript. Thank you again for your time and thoughtful evaluation.

We look forward to your continued review.

 

Reviewer’s Comments and Suggestions for Authors

This manuscript attempts to provide a systematic way to help schizophrenia patients to recover physical activity to some extent by reviewing the existing literature. It also provides a comprehensive approach of physical rehabilitation for each motor-related dysfunction that the authors identified.

However, the manuscript does not describe a guideline in clinical settings, how practitioners identify and categorize the motor dysfunctions in schizophrenia into three categories and design rehabilitation plans accordingly. The authors should address this issue.

 

Response: Thank you for your constructive feedback on our manuscript. We sincerely appreciate your valuable insight that the paper would be more practical and impactful by providing guidance on how to apply our proposed framework in a clinical setting. Your suggestion has significantly strengthened our work.

In response to your comments, we have revised and expanded our section on " Practical Applications and Clinical Workflow" (now Section 5.4). This integrated section now includes a clear and actionable clinical workflow, transforming our conceptual model into a tangible, step-by-step guide for practitioners. This new content illustrates how clinicians can: 1) Conduct a Holistic and Granular Assessment using objective tools to identify the unique contributors to physical decline; 2) Categorize these dysfunctions into our three-domain framework; 3) Develop a Precision Rehabilitation Plan that is highly individualized and tailored to the patient's specific domain; and 4) Engage in Continuous Reassessment to adapt interventions as the patient's condition evolves.

We believe that this addition transforms our conceptual framework into a tangible, practical tool for clinicians, directly addressing your insightful suggestions. We are confident that these revisions have enhanced the manuscript's clarity and clinical utility, and we thank you again for the opportunity to improve our work.

 

A few small points:

 

• In both the abstract and the introduction, the authors started describing schizophrenia using Japan’s epidemiology data, which could lead readers to think that the study is based on Japan’s population, but the manuscript is not limited to Japan. So please incorporate worldwide epidemiology data.

 Response: To focus on psychiatric physical rehabilitation from a global perspective, we have removed the discussion points regarding Japanese psychiatric care. Thank you for your advice.

• 1 seems oversimplified. The authors still need to describe what the method is in this manuscript.

Response: Thank you for your suggestion. We have revised figures 1 and 2 according to the changes from the conceptual paper to the review paper, which includes the methods.

• In Figure 1. The 2^nd textbox seems to contain the quote symbols “[]” from a non-English input method. Please change the symbols.

Response: The Instructions for Authors of this journal state the following: "In the text, reference numbers should be placed in square brackets and before the punctuation. For example, [1], [1–3], or [1, 3]." Therefore, we have followed this citation method here. We appreciate your understanding.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have substantially restructured the paper into a narrative review built around a clear three-domain framework: antipsychotic-related motor dysfunction; dynapenia/sarcopenia/sarcopenic obesity/frailty; and neuro-motor and cognitive deficits.  The taxonomy is now applied consistently throughout, including in Figures 1–2.  The Methods section clearly defines the review type and search scope (English-only PubMed, January 2014–January 2025) and follows a “conceptual study storyline”.  To enhance clinical relevance, Tables 1–3 now align “Rationale & Key Interventions” with schizophrenia-specific features, assessments, and comparative insights, and Section 5.4 introduces a four-step Clinical Workflow (assessment, domain categorization, tailored program, reassessment) linking mechanisms to interventions.  The authors also add a selection diagram summarizing database totals and study counts (e.g., PubMed n = 2,089), improving transparency while remaining within a narrative, non-PRISMA format.  Overall, the revision produces a coherent, clinically oriented framework grounded in measurable tests and progression logic.

Remaining issues are minor.  The main inconsistency lies between the response letter (stating PubMed/MEDLINE and Web of Science searches) and the revised manuscript, which specifies PubMed only; the Abstract and Methods should reflect this consistently.  Section 4.2 also repeats a paragraph on occupational therapy and should be de-duplicated.  In the selection figures, captions should clarify what the reported counts represent (e.g., citations vs. screened records) to prevent confusion.  Finally, a light language edit would help eliminate minor redundancies and formatting slips.

Author Response

Dear Reviewer,

Thank you for taking the time to review our manuscript multiple times. All revisions have been highlighted in red font. We sincerely appreciate your thoughtful and considerate review.

Comments: The main inconsistency lies between the response letter (stating PubMed/MEDLINE and Web of Science searches) and the revised manuscript, which specifies PubMed only; the Abstract and Methods should reflect this consistently.  

Response: Thank you for pointing out this inconsistency. We have revised the manuscript to ensure consistency, specifying PubMed as the only database used throughout the Abstract and Methods sections.

Comments: Section 4.2 also repeats a paragraph on occupational therapy and should be de-duplicated.  
Response: Thank you for your careful review. We have removed the duplicates per your suggestion.

Comments: In the selection figures, captions should clarify what the reported counts represent (e.g., citations vs. screened records) to prevent confusion. 

Response: The text has been revised to clarify how many papers were screened and ultimately selected.

Comments: Finally, a light language edit would help eliminate minor redundancies and formatting slips.

Response: The manuscript has been rechecked and proofread by a professional English editing service.

 

Reviewer 4 Report

Comments and Suggestions for Authors

The authors have addressed all my concerns in the previous round. 

Author Response

Thank you for taking the time to review our paper.