PONE-D-25-13944‘Task-Oriented Training in Stroke Rehabilitation: Qualitative study on Perspectives and Challenges among Pakistani Physiotherapists’PLOS ONE

Dear Dr. Afridi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 09 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Nadinne Alexandra Roman, Ph.D.

Academic Editor

PLOS ONE

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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

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: 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: The manuscript presents valuable insights into the use of Task-Oriented Training (TOT) in stroke rehabilitation among physiotherapists in Pakistan. However, there are several areas that require clarification, restructuring, and additional evidence to strengthen the study's scientific rigor and presentation.

Abstract:

• Abbreviate Task-Oriented Training as TOT upon its first mention and use the abbreviation consistently throughout the manuscript.

• The results section of the abstract may include numerical values derived from the data analysis (e.g., percentage of therapists using TOT, common barriers identified, response rates) as applicable.

Introduction:

• Replace vague expressions like “with the rising incidence of stroke in LMICs” with quantitative epidemiological data, citing specific incidence or prevalence rates.

• The statement “influences survivors' ability to resume work” should specify the age group most affected, supported by relevant literature.

• Clarify or provide citation evidence for the following claim:

“However, while TOT has been extensively considered in Western contexts of rehabilitation, its application in LMICs, particularly in Pakistan, remains underexplored.”

Include region-specific studies or a literature gap analysis to support this assertion.

References:

• Reference no. 10 is not accessible—please provide a valid source or replace with an alternative that is publicly available.

• Ensure all citations used to support methodology or clinical practice (especially those describing rehabilitation procedures) are appropriately cited.

Methodology:

• Sample Size: Justify why only 22 therapists were selected for purposive sampling. Explain whether saturation was achieved.

• Questionnaire Validation: Clearly state:

o How many therapists were involved in validating the semi-structured interview tool?

o Their qualifications and professional background.

o Whether these therapists had prior knowledge or experience with TOT (as part of inclusion criteria).

• Language of Questionnaire: Specify the language in which the questionnaire was developed and administered.

• Content Validation: Confirm if the tool explicitly assesses whether the participants are acquainted with the TOT approach.

Data Analysis:

• Report response rates across different sections/domains of the semi-structured questionnaire.

• Include any correlation or association found between participant characteristics (e.g., experience level, clinical setting) and the use or understanding of TOT.

• Ensure the similarity index of the manuscript is <10% and revise any plagiarized or overly similar content from prior publications.

Results:

• Present all findings using numerical values, e.g.,

o “68% of therapists use TOT in upper limb rehabilitation”

o “Only 27% of therapists incorporate cognitive tasks into sessions”

• When reporting themes from qualitative analysis, quantify the responses where possible (e.g., “12 out of 22 participants identified lack of training as a barrier”).

Discussion:

• Begin the discussion section with a summary of key findings.

• Compare your findings with existing studies or systematic reviews, particularly from LMICs or similar rehabilitation settings.

• Offer explanations for any discrepancies between your findings and prior research.

• Discuss the strength of the evidence supporting TOT’s effectiveness, referencing high-quality studies (e.g., RCTs, meta-analyses) that support its use in stroke rehabilitation.

Reviewer #2: Strengths:

The use of a qualitative descriptive methodology with Braun & Clarke's six-step thematic analysis is appropriate and rigorously applied.

The study addresses a significant gap in rehabilitation literature from low-resource settings.

Ethical considerations, participant diversity, and reflexivity practices are commendable.

Results are well-structured into meaningful themes that reflect both practice and systemic realities.

Suggestions for Improvement:

Consider slightly condensing some repetitive statements in the introduction and discussion for improved readability.

Some grammatical and syntax refinements (minor) are recommended; for instance, changing “has extensively reported” to “have extensively reported” (line 91) for subject-verb agreement.

A brief table summarizing key themes and subthemes with representative quotes would enhance the clarity of findings.

Overall, this manuscript presents valuable insights into the real-world implementation of TOT in a low-resource setting and has practical implications for education, policy, and future research. I recommend acceptance with minor language editing.

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Reviewer #1: No

Reviewer #2: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PONE-D-25-13944R1‘Task-Oriented Training in Stroke Rehabilitation: Qualitative study on Perspectives and Challenges among Pakistani Physiotherapists’PLOS ONE

Dear Dr. Afridi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 02 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Nadinne Alexandra Roman, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. 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: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. 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: The description of the sampling method is generally clear; however, a few points require clarification and elaboration. First, while purposive sampling is for targeting experienced professionals, the rationale behind selecting only physiotherapists with a Master’s degree in Neuro-Muscular Physical Therapy should be explained more explicitly. Clarifying whether this criterion was intended to ensure a homogeneous expert group or to reflect a standard qualification in the region would strengthen the methodological justification. Is it intended in inclusion criteria??

Additionally, while the recruitment sources are diverse, it would be helpful to discuss any potential selection biases that may arise from relying on professional associations and academic networks. Please comment on whether this urban and semi-urban focus was intentional and how it may affect the generalizability of findings.

Finally, consider providing brief information on how many participants were expected from each source for sample composition.

Reviewer #2: The content sounds good and appreciating your efforts for revision. The discussion and methodology are approriate

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: Yes:  Sridhar Arumugam

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

‘Task-Oriented Training in Stroke Rehabilitation: Qualitative study on Perspectives and Challenges among Pakistani Physiotherapists’

PONE-D-25-13944R2

Dear Dr. Afridi,

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.

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.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Nadinne Alexandra Roman, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. 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: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. 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: The description of the methodology in the abstract could be more detailed to give readers a clearer understanding of the study’s design and approach. Additionally, it would strengthen the manuscript if the authors briefly mentioned the key strengths and limitations of their study

Reviewer #2: The revised manuscript titled “Task-Oriented Training in Stroke Rehabilitation: Qualitative Study on Perspectives and Challenges among Pakistani Physiotherapists” provides valuable insights into the implementation of task-oriented training (TOT) in low-resource contexts. The authors have addressed previous reviewer comments thoroughly and have enhanced the methodological rigor of the manuscript. Key strengths of this study include:

Clear justification for using qualitative descriptive methodology.

Thoughtful sampling of experienced neurorehabilitation physiotherapists.

Systematic thematic analysis using Braun and Clarke's six-step framework.

Culturally grounded insights that address practical barriers to implementing TOT in Pakistan.

The addition of detailed explanations regarding the purposive sampling strategy (focused on master's-level neurorehabilitation-trained physiotherapists) and recruitment from urban/semi-urban settings provides useful context. The authors' acknowledgment of limitations related to rural underrepresentation is appreciated.

The themes identified are well-developed and aligned with existing literature. Importantly, the authors go beyond surface-level findings and present nuanced views on cognitive rehabilitation and cultural barriers.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: Yes:  SRIDHAR ARUMUGAM

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