Neurohabilitation Through LEGO^®-Based Therapy for Cognitive Functions in Down Syndrome

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review your manuscript describing a LEGO®-based neurorehabilitation intervention for an individual with Down syndrome. The topic is creative and may have potential clinical and educational relevance. However, the manuscript in its current form does not meet the scientific, linguistic, or ethical standards required for publication.

Although you have correctly defined the submission as a case report, the article lacks the structural and conceptual rigor expected in this format. The discussion should emphasize the illustrative value of the case and not imply general or causal conclusions.

The terminology used throughout the article is problematic and requires significant revision. Down syndrome is not a disease but a chromosomal condition. Expressions such as “patient” or “sufferer” are inappropriate and should be replaced with “person with Down syndrome” or “participant”. Consistent use of person-centered, respectful, and precise language is essential.

The quality of academic writing also needs significant improvement. The manuscript contains numerous grammatical errors and unclear wording, which impair its readability and professionalism. A full linguistic and stylistic editing by an experienced academic English editor is highly recommended.

Finally, the interpretation of the findings is exaggerated. Please present this report as an exploratory and illustrative case, while acknowledging its inherent methodological limitations and avoiding claims of therapeutic efficacy.

In its current form, the manuscript requires significant conceptual, linguistic, and ethical edits to meet publication standards.

Author Response

Thank you for the opportunity to review your manuscript describing a LEGO®-based neurorehabilitation intervention for an individual with Down syndrome. The topic is creative and may have potential clinical and educational relevance. However, the manuscript in its current form does not meet the scientific, linguistic, or ethical standards required for publication.

Although you have correctly defined the submission as a case report, the article lacks the structural and conceptual rigor expected in this format. The discussion should emphasize the illustrative value of the case and not imply general or causal conclusions.

R: The conclusions were based on the findings from the neuropsychological assessments conducted before and after treatment. No qualitative data were collected in this regard. The purpose of this case study was to illustrate potential changes that may occur before and after a neurorehabilitation intervention that has been previously standardized in other populations. However, we modified the discussion, adding a subsection on the limitations and implications of the study and future research.

The terminology used throughout the article is problematic and requires significant revision. Down syndrome is not a disease but a chromosomal condition. Expressions such as “patient” or “sufferer” are inappropriate and should be replaced with “person with Down syndrome” or “participant”. Consistent use of person-centered, respectful, and precise language is essential.

R: It was reviewed and modified.

The quality of academic writing also needs significant improvement. The manuscript contains numerous grammatical errors and unclear wording, which impair its readability and professionalism. A full linguistic and stylistic editing by an experienced academic English editor is highly recommended.

R: It was reviewed and modified.

Finally, the interpretation of the findings is exaggerated. Please present this report as an exploratory and illustrative case, while acknowledging its inherent methodological limitations and avoiding claims of therapeutic efficacy.

R: As stated in our conclusions, the intervention may benefit the described cognitive processes. Furthermore, we emphasize that this approach has strong potential for other populations, as reported in previous studies on this type of therapy.

In its current form, the manuscript requires significant conceptual, linguistic, and ethical edits to meet publication standards.

R: The linguistic recommendations have been addressed. However, the conceptual aspects cannot be modified due to the limited existing literature on this topic and on neurorehabilitation using LEGO-based therapy. Therefore, it is crucial to continue generating new knowledge about technologies and neurotherapies that could benefit individuals with cognitive deficits. The ethical considerations have been detailed and confirmed as reviewed and approved by our institutional committees.

Thank you for your helpful comments, which improved the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

This case report offers an innovative application of LEGO®-based neurohabilitation therapy in an adolescent with Down syndrome, demonstrating measurable cognitive gains supported by the use of the Reliable Change Index (RCI). The intervention’s structured and progressively complex design, combining play and technology to stimulate cortical plasticity, represents a creative and clinically meaningful approach within neurodevelopmental rehabilitation.

Main limitations identified:

• The single-case design limits generalizability and precludes causal inference; potential maturation and practice effects are not controlled.

• The participant’s comorbid congenital heart disease and congenital cataract are not sufficiently discussed as possible confounders influencing baseline function and therapeutic response.

• Psychometric suitability of the BANFE-3, Rey Figure, and Five Digits Test for an adolescent with intellectual disability is not critically examined; possible floor effects should be acknowledged.

• The developmental appropriateness of LEGO® WeDo 2.0 materials (typically for younger children) is not justified in relation to the patient’s cognitive rather than chronological age.

• Heavy reliance on self-citing literature and limited discussion of non-significant RCI results (e.g., verbal fluency, alternating attention).

Suggestions for improvement:
Future revisions should clearly acknowledge the limits of a single-case design and discuss how subsequent multi-baseline or randomized controlled studies could confirm these findings. The authors should expand the methodological section to justify the test selection and material choice relative to the patient’s developmental profile and specify psychometric parameters used in RCI computation. Discussion of comorbidities’ potential impact on cognitive outcomes would add valuable nuance. Including more independent literature, tempering generalizations, and refining the English expression will enhance both the rigor and readability of the manuscript. With these adjustments, the study would stand as a strong contribution to emerging evidence on technology-mediated neurohabilitation in Down syndrome.

Author Response

This case report offers an innovative application of LEGO®-based neurohabilitation therapy in an adolescent with Down syndrome, demonstrating measurable cognitive gains supported by the use of the Reliable Change Index (RCI). The intervention’s structured and progressively complex design, combining play and technology to stimulate cortical plasticity, represents a creative and clinically meaningful approach within neurodevelopmental rehabilitation.

Main limitations identified:

• The single-case design limits generalizability and precludes causal inference; potential maturation and practice effects are not controlled.

R: This has been a topic of discussion in previous studies. However, we understand its limitations. For this reason, we focused on the effects before and after treatment. Though few studies have addressed this topic, the existing literature suggests that the intervention may produce different outcomes compared to patients who do not receive it. We added a subsection on the limitations of the study.

The participant’s comorbid congenital heart disease and congenital cataract are not sufficiently discussed as possible confounders influencing baseline function and therapeutic response.

R: It has been added to the discussion accordingly.

• Psychometric suitability of the BANFE-3, Rey Figure, and Five Digits Test for an adolescent with intellectual disability is not critically examined; possible floor effects should be acknowledged.

R: An explanation of the selection of these subprocesses and subtests has been added to the Assessment section. A preliminary pilot study was conducted to identify the most suitable and valid tests for our population. Based on the results of this study, the measures selected were deemed the most appropriate for this context.

The developmental appropriateness of LEGO® WeDo 2.0 materials (typically for younger children) is not justified in relation to the patient’s cognitive rather than chronological age.

R: The WeDo 2.0 set is used with patients of all ages as part of the cognitive neurohabilitation protocol described in the manuscript. Rather than focusing on using the material according to its intended age group, the therapy incorporates the material as an integral component of the therapeutic process itself. This flexibility enables the material to be assembled and adapted for different robotic problem-solving tasks, making it suitable and engaging for individuals of various ages and abilities.

• Heavy reliance on self-citing literature and limited discussion of non-significant RCI results (e.g., verbal fluency, alternating attention).

R: The existing literature on neurohabilitation is limited, especially in the context of Down syndrome. The National Institute of Pediatrics in Mexico has developed this particular line of research on LEGO-based neurohabilitation. The research is currently in an active stage of growth and is being expanded to explore its application across a range of neurocognitive syndromes.

Suggestions for improvement:
Future revisions should clearly acknowledge the limits of a single-case design and discuss how subsequent multi-baseline or randomized controlled studies could confirm these findings. The authors should expand the methodological section to justify the test selection and material choice relative to the patient’s developmental profile and specify psychometric parameters used in RCI computation. Discussion of comorbidities’ potential impact on cognitive outcomes would add valuable nuance. Including more independent literature, tempering generalizations, and refining the English expression will enhance both the rigor and readability of the manuscript. With these adjustments, the study would stand as a strong contribution to emerging evidence on technology-mediated neurohabilitation in Down syndrome.

R: We will add a discussion of comorbidities as a limitation of the study in the hope that more people with Down syndrome will enter the study protocol in the future. Additionally, we have expanded the discussion by adding more references from the study (considering that there are few studies of this type), and we have revised the English.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review your manuscript. I was initially excited when I read the title and abstract to learn more about LEGO-based neurohabilitation therapy from a case study approach. The authors provide a detailed description of Down Syndrome with connections to literature. The authors provide a brief introduction to neurohabilitation based on LEGO therapy. I think this can be expanded upon with a stronger explanation for the need /rationale for this research.

My biggest concern is the use of the term “case study” without a clear description of the case study approach used with a connection to relevant literature. It is often expected to have a smaller number of participants with a case study. However, one participant with limited data points to triangulate in detail is not the norm. The authors need to provide literature to support research that contains only one participant with limited data points. The phenomenon is not described in detail. A table is included about the sessions, objectives, tasks, and sets used. However, there are no field notes to describe the sessions, interviews with the participant or psychologist administering the sessions, or multimodal analysis of the sessions, to name a few examples of additional potential data points to triangulate the data and better describe the phenomenon that one would expect with a case study. The discussion section is also rather short and does not engage fully with relevant literature. The discussion needs to provide detailed sub-sections outlining limitations, implications, and future research.

This article shows great potential but does not contain enough of the essential components of a case study research article in the present submission. I encourage the authors to add more specific detail throughout., especially about case study research and how this article aligns with relevant case study literature. Please review some more targeted recommendations below.

Recommendations for Authors:

1. Please review the journal formatting for in-text citations. I have included the language below to inform your revisions of in-text citations for references in the main text that align with references in the references list.
   1. In the text, reference numbers should be placed in square brackets [ ], and placed before the punctuation; for example [1], [1–3] or [1,3]. For embedded citations in the text with pagination, use both parentheses and brackets to indicate the reference number and page numbers; for example [5] (p. 10). or [6] (pp. 101–105).
2. Page 1, line 33
   1. Delete the word “The” to start the sentence.
3. Page 1, line 40
   1. Consider revising the word “patients” to a non-clinical term, such as “individuals”
4. Page 2, line 85
   1. Delete extra period at end of sentence.
5. Page 3, line 95-96
   1. What do you mean by “describes a good relationship with her family”? I would rephrase for clarity.
6. Page 3, lines100-104
   1. I would recommend that you add a citation for the sentence where you introduce information about the measure used.
7. Pages 4-5
   1. Please ad a title for the Table. Recommend reviewing the formatting guides provided by the journal.
   2. Unclear why the number 9 is highlighted.
8. Materials and Methods
   1. How was the participant recruited?
   2. Were the authors involved in completing the assessments or administering the LEGO therapy?
   3. Case Study
      1. The title indicates that this is a case study. However, there is no information to explain why a case study approach was used and how it aligns with literature on a case study approach for research. This needs to be explicitly incorporated into the manuscript and more about the rationale for using a case study approach needs to be explained.
   4. What is the setting for the research? More contextual information would be beneficial.
9. Results & Discussion formatting
   1. Please review the formatting of this section. Additional spacing was added in between paragraphs that was not present in previous section. I would recommend reviewing the formatting guide provided by the journal.
10. Discussion
    1. This section needs to be expanded with more connections to the current evidence base.
    2. Please add a separate sub-section to explicitly highlight the limitations of this manuscript.
       1. For example, you only had one participant, so the findings are not generalizable. You list single-case design as a limitation, but this study is not a single-case design study. If you are implying the study only having one participant is a limitation, then you need to state that. The term “single-case design” is a methodology. That statement is very confusing. (page 8 lines 235-236)
       2. Also, the lack of qualitative data and the triangulation of data that one would expect in a case study, especially with only one participant. More detailed information about the implementation of the intervention, as well as feedback from the participant, those implementing the therapy, and the participant’s family would greatly enhance the overall quality of this work.
    3. Please add a separate sub-section for implications of this work.
       1. What are the explicit implications of this work for the field.
    4. Please add a separate sub-section for Future Research.
       1. What recommendations do you have based on the current study for future research.
    5. Conclusion
       1. Consider revising the word “tolerated” in the conclusions section.

Author Response

Thank you for the opportunity to review your manuscript. I was initially excited when I read the title and abstract to learn more about LEGO-based neurohabilitation therapy from a case study approach. The authors provide a detailed description of Down Syndrome with connections to literature. The authors provide a brief introduction to neurohabilitation based on LEGO therapy. I think this can be expanded upon with a stronger explanation for the need /rationale for this research.

My biggest concern is the use of the term “case study” without a clear description of the case study approach used with a connection to relevant literature. It is often expected to have a smaller number of participants with a case study. However, one participant with limited data points to triangulate in detail is not the norm. The authors need to provide literature to support research that contains only one participant with limited data points. The phenomenon is not described in detail. A table is included about the sessions, objectives, tasks, and sets used. However, there are no field notes to describe the sessions, interviews with the participant or psychologist administering the sessions, or multimodal analysis of the sessions, to name a few examples of additional potential data points to triangulate the data and better describe the phenomenon that one would expect with a case study. The discussion section is also rather short and does not engage fully with relevant literature. The discussion needs to provide detailed sub-sections outlining limitations, implications, and future research.

R: Currently, there is no published literature on neurohabilitation across different syndromes. This is an emerging field of research that includes various pathologies in its descriptions of findings. We appreciate your interest in developing this area further. However, scientific progress is based on publishing novel cases and innovations. This therapy has only been replicated a few times worldwide, showing promising results in basic models of autism, as well as in neurohabilitation studies involving congenital heart disease and epilepsy. To our knowledge, it has not yet been reported in other syndromes, which explains the scarcity of available information. The data presented here represent the information currently accessible to us. We added limitations to the study, which will be considered in future research involving a larger number of cases.

This article shows great potential but does not contain enough of the essential components of a case study research article in the present submission. I encourage the authors to add more specific detail throughout., especially about case study research and how this article aligns with relevant case study literature. Please review some more targeted recommendations below.

Recommendations for Authors:

1. Please review the journal formatting for in-text citations. I have included the language below to inform your revisions of in-text citations for references in the main text that align with references in the references list.
1. In the text, reference numbers should be placed in square brackets [ ], and placed before the punctuation; for example [1], [1–3] or [1,3]. For embedded citations in the text with pagination, use both parentheses and brackets to indicate the reference number and page numbers; for example [5] (p. 10). or [6] (pp. 101–105).

       R: The citations were modified according to the journal format.

1. Page 1, line 33
1. Delete the word “The” to start the sentence.

R: The word was eliminated

1. Page 1, line 40
1. Consider revising the word “patients” to a non-clinical term, such as “individuals”

R: The word “patients” was changed by people

1. Page 2, line 85
1. Delete extra period at end of sentence. R:The extra period was deleted.

1. Page 3, line 95-96
1. What do you mean by “describes a good relationship with her family”? I would rephrase for clarity.

R: The sentence was changed

1. Page 3, lines100-104
1. I would recommend that you add a citation for the sentence where you introduce information about the measure used.

R: The cite was added

1. Pages 4-5
1. Please ad a title for the Table. Recommend reviewing the formatting guides provided by the journal.

R: The title of the Table was added

1. Unclear why the number 9 is highlighted.

R: The highlighted was eliminated

1. Materials and Methods
1. How was the participant recruited?

R: The participant was referred to the study by the hospital’s Down Syndrome Clinic. The clinic informed the mother and participant about the protocol. Both expressed interest in learning about the project, requested information, received it, and agreed to participate.

1. Were the authors involved in completing the assessments or administering the LEGO therapy?

R: One of the authors participated in the pretest evaluation, and another participated in the posttest evaluation. One of the therapists from the unit carried out the intervention under the supervision of another author.

Case Study

1. 1. 1. The title indicates that this is a case study. However, there is no information to explain why a case study approach was used and how it aligns with literature on a case study approach for research. This needs to be explicitly incorporated into the manuscript and more about the rationale for using a case study approach needs to be explained.

R: It was a case study because a larger sample size was initially expected. However, recruiting participants proved challenging since most discontinued the treatment. Only one participant completed the intervention. Ideally, we would present results from a larger group, but developing countries have significant logistical limitations. Hospitals are often far from participants' homes, requiring families to invest considerable time and resources. Travel times to attend each session can be up to two or three hours.

We hope that future studies will be able to recruit more participants and generate stronger evidence on the intervention's effectiveness.

1. What is the setting for the research? More contextual information would be beneficial.

R: First of all, neurohabilitation is a new and still scarcely studied concept, which initially limited its acceptance within the medical field. Once we succeeded in implementing it, we encountered several challenges, such as the long distances between the hospital and the participants’ homes, as well as the transportation costs involved.

However, the participant’s mother, upon observing her daughter’s progress, became increasingly motivated to attend the sessions. She mentioned that her daughter came to the robotics therapy very happy, and they did not miss a single intervention.

Not all patients were able to maintain such consistency. This is a public hospital, and although the intervention and assessments are provided free of charge, transportation and other related expenses can represent a significant burden for families.

 

1. Results & Discussion formatting
1. Please review the formatting of this section. Additional spacing was added in between paragraphs that was not present in previous section. I would recommend reviewing the formatting guide provided by the journal.

R: The format was revised and corrected

1. Discussion
1. This section needs to be expanded with more connections to the current evidence base.

R: After conducting an exhaustive search, not many more references were found in the literature where LEGO therapy is applied to people with DS. Only a few data from two other references were added.

1. Please add a separate sub-section to explicitly highlight the limitations of this manuscript.
1. For example, you only had one participant, so the findings are not generalizable. You list single-case design as a limitation, but this study is not a single-case design study. If you are implying the study only having one participant is a limitation, then you need to state that. The term “single-case design” is a methodology. That statement is very confusing. (page 8 lines 235-236)
2. Also, the lack of qualitative data and the triangulation of data that one would expect in a case study, especially with only one participant. More detailed information about the implementation of the intervention, as well as feedback from the participant, those implementing the therapy, and the participant’s family would greatly enhance the overall quality of this work.

R: The limitations of the study were added

1. Please add a separate sub-section for implications of this work.
1. What are the explicit implications of this work for the field.

R: The implications of the study section were added

1. Please add a separate sub-section for Future Research.
1. What recommendations do you have based on the current study for future research.

R: The Future research subsection was added

1. 1. Conclusion. Consider revising the word “tolerated” in the conclusions section. R: The word was changed

Thank you for your helpful comments, which improved the manuscript.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Having reviewed the revisions, I confirm that all comments have been adequately addressed and the manuscript is ready for publication

Author Response

Dear Reviewer:

We appreciate your kind comments and are grateful that they helped improve the manuscript.

 

Reviewer 2 Report

Comments and Suggestions for Authors

Authors have successfully addressed most of my concerns (those that haven't would have required another different desing for the study) and I do believe the manuscript quality has significantly improved. No more comments to add. 

Author Response

Dear Reviewer:

We appreciate your kind comments and are grateful that they helped improve the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review your revised manuscript and for the reponses you provided to reviewer feedback. Some of the comments you provided were present in your response to reviewers, but not in the manuscript. For example, you detailed limitations of the research, such as the ability for participants to travel for the therapy should be outlined in the limitations section. Please see additional suggestions for improvement below.

 

Suggestions for authors:

1. Review font and formatting of Limitations seciton on pages 8-9.
2. Methods
   1. Nothing was added, that I coudl find, to the manuscript to explain the use of the term case study. Relevant literature should be included describing what a case study is and what you did that demonstrates a case study approach. One would expect to read connections to case study literature and information describing the specific phenomenon being studied.
   2. If the authors choose not to describe how they used a case study approach with connections to relevant literature, then the authors must remove "case study" from the title and the manuscript. Just having one participant doesn't make it a case study. Perhaps your research might be better described as a pilot study with connections to pilot study literature to explain the number of participants and future research aspirations of the authors. 
3. Page 8, lines 228-229
   1. Should have a citation.
4. Page 8, line 240
   1. Need brackets for in-text citation; [26, 27]
5. Implications Section
   1. This section needs to be expanded with greater detail. 
   2. Please provide more specific information explaining how the findings can impact theory, practice, and future research in the relevant context.
6. Future Research, page 9, line 279
   1. I would rephrase this sentence to what future research should do. 
7. You have a lot of overlap in describing future research in the limitations and implications section. I would consider combining the Limitations and Future Research into one subsection so it isn't across multiple sections to provide greater clarity.

Author Response

Thank you for the opportunity to review your revised manuscript and for the reponses you provided to reviewer feedback. Some of the comments you provided were present in your response to reviewers, but not in the manuscript. For example, you detailed limitations of the research, such as the ability for participants to travel for the therapy should be outlined in the limitations section. Please see additional suggestions for improvement below.

 

Suggestions for authors:

1. Review font and formatting of Limitations seciton on pages 8-9.

R: Thank you for the observation. We changed the font of Limitation section

Methods

1. 1.Nothing was added, that I coudl find, to the manuscript to explain the use of the term case study. Relevant literature should be included describing what a case study is and what you did that demonstrates a case study approach. One would expect to read connections to case study literature and information describing the specific phenomenon being studied.

R: As explained, from the initial sample of participants who discontinued the treatment, only one participant completed it; therefore, this is a case study. According to the method described, it should be reported as a case study based on our design. If the term does not align with the journal’s guidelines, it can be removed; however, we will consult the editor regarding this matter.

 

2. If the authors choose not to describe how they used a case study approach with connections to relevant literature, then the authors must remove "case study" from the title and the manuscript. Just having one participant doesn't make it a case study. Perhaps your research might be better described as a pilot study with connections to pilot study literature to explain the number of participants and future research aspirations of the authors. 

R: The method is described, and it cannot be considered a pilot study because this therapy has previously been tested in other conditions. It could only be classified as a pilot study if the therapy had not been described before; in this case, the only difference is the new etiology in which it is applied and explained in detail.

1. Page 8, lines 228-229
1. Should have a citation.

R: Thank you. The references were added

1. Page 8, line 240
1. Need brackets for in-text citation; [26, 27]

R: Thank you. The references have brackets

1. Implications Section
1. This section needs to be expanded with greater detail. 
2. Please provide more specific information explaining how the findings can impact theory, practice, and future research in the relevant context.

R: A paragraph about implications was added.

1. Future Research, page 9, line 279
1. I would rephrase this sentence to what future research should do. 

R: Thank you. This section was combined with limitations

1. You have a lot of overlap in describing future research in the limitations and implications section. I would consider combining the Limitations and Future Research into one subsection so it isn't across multiple sections to provide greater clarity.

R: Thank you. The sections were rewritten and combined for better understanding.

 

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors

My continued concern about this article is the use of "case study" in the manuscript. You took the term out of the title, but it is still used throughout the manuscript. You did not add in any connections to relevant case study literature to describe this as an approach used in your Methods section. Based on your responses, it is unclear if you know what a case study approach is in research. Case study is not a default method because of one participant. It is a specific approach with a strong research base. I would recommend you review relevant case study literature, such as Stake (1995) to determine if this research is a case study. If it is, then literature needs to be included to support that in the methods section. Otherwise, the case study terminilogy needs to be removed from the manuscript. I would not publish this article until this has been addressed. 

Author Response

Comment:

My continued concern about this article is the use of "case study" in the manuscript. You took the term out of the title, but it is still used throughout the manuscript. You did not add in any connections to relevant case study literature to describe this as an approach used in your Methods section. Based on your responses, it is unclear if you know what a case study approach is in research. Case study is not a default method because of one participant. It is a specific approach with a strong research base. I would recommend you review relevant case study literature, such as Stake (1995) to determine if this research is a case study. If it is, then literature needs to be included to support that in the methods section. Otherwise, the case study terminilogy needs to be removed from the manuscript. I would not publish this article until this has been addressed. 

Response

Dear Reviewer,

We appreciate your comment. After reviewing the methodology of our social research, we decided to classify it as a "pre-experimental study" based on your comment. The design includes a pre-test and post-test of a single clinical case, but lacks a comparison or control group. In light of this, we have updated the study design by changing "case study" to "pre-experimental study."

Campbell, D., & Stanley, J. (1963). Experimental and Quasi-Experimental Designs for Research. Chicago, IL: Rand McNally.

Salas Blas, E. "Pre-Experimental Designs in Psychology and Education: A Conceptual Review." Liberabit. Peruvian Journal of Psychology. 2013; 19(1): 133–141.

Round 4

Reviewer 3 Report

Comments and Suggestions for Authors

I support this manuscript being accepted with minor revisions. The new language included is a better representation of the research described. I would recommend that you include a citation within the methods section to align with the reference you included in your response to reviewer feedback. That will better situate this research within the methodological approach described.

Author Response

Comment:

I support this manuscript being accepted with minor revisions. The new language included is a better representation of the research described. I would recommend that you include a citation within the methods section to align with the reference you included in your response to reviewer feedback. That will better situate this research within the methodological approach described.

Response:

Dear Reviewer:

We appreciate comments that help us improve the article. We added the requested reference where we mention the study's classification or design. Thank you