Research design

Qualitative descriptive design and a thematic framework was used in this study to explore TOT experiences, practices, and perspectives of physiotherapists in Pakistan. This approach captures detailed narratives and complex experiences. A qualitative descriptive design was selected because the main aim was to provide a comprehensive, data-driven account of current TOT practices with straightforward representation of participant perspectives. A thematic framework approach guided data analysis, allowing for the systematic identification, organization, and interpretation of key themes emerging from the data. [22] Specifically, Braun and Clarke’s six-step thematic analysis [23] was used to ensure a structured and rigorous process of data organization, coding, and interpretation. This study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Sample size and participants characteristics

A sample of 22 physiotherapists was recruited based on purposive sampling, ensuring that all participants had at least five years of clinical experience in stroke rehabilitation and held a Master’s degree in Neuro-Muscular Physical Therapy. The inclusion criterion of a Master’s degree in Neuro-Muscular Physical Therapy was selected to ensure a homogeneous sample of physiotherapists with advanced training and specialization in stroke rehabilitation. This qualification reflects the minimum advanced educational standard for neuro-rehabilitation expertise in Pakistan and was intended to ensure that participants possessed sufficient theoretical and clinical insight into the application of task-oriented training in neuro-muscular disorders.

Participants were recruited through professional physiotherapy associations, academic networks, and direct referrals from rehabilitation centers in urban and semi-urban areas of Pakistan. The recruitment period for this study was from September 15, 2022, to October 25, 2022. The sample size was determined using data saturation as a guiding principle, where no new themes or variations in responses emerged from additional interviews, indicating a comprehensive exploration of the phenomenon [24]. To document saturation, a saturation table was maintained, (S3 in Supporting information) systematically tracking themes, sub-themes, and their recurrence across interviews. Saturation was assessed inductively with emerging codes refined iteratively throughout the analysis. No additional participants were recruited once thematic redundancy was reached in the last two interviews.

Data collection procedure

To minimize interviewer bias, four trained female researchers (UA, MR, AI and NR) with a Doctor of Physical Therapy degree conducted the interviews. Training emphasized unbiased questioning techniques, active listening, and neutral prompting to avoid leading responses. Additionally, standardized semi-structured interview protocols were used to ensure consistency across interviews. A total of 22 interviews were conducted, held face-to-face in their rehabilitation clinics. Privacy was ensured, and all sessions were audio-recorded with participant consent for accurate transcription and analysis. Non-verbal cues were carefully recorded in the notes.

Power dynamics between interviewers and participants were carefully managed by:

• Conducting interviews in neutral, private settings to reduce hierarchical influences.
• Encouraging participants to speak freely and critically, ensuring they felt comfortable sharing both positive and negative experiences.
• Using non-verbal rapport-building techniques to create a conversational rather than interrogative environment.

Reflexivity discussion

Given that the interviewers were physiotherapists, their professional backgrounds could have influenced the way questions were framed and how participants responded. To address researcher position, reflexive memos were maintained throughout data collection and analysis, documenting personal biases, assumptions, and reflections on participant responses. Researchers maintained reflexivity by cross-checking interpretations with an external expert to minimize personal biases.

The interview format was based on participant preference and logistics, maintaining consistency through standardized protocols and questions. The semi-structured interview guide was validated by three independent expert physiotherapists each holding a Master’s degree in Neuro-Muscular Physical Therapy and with ≥7 years of clinical experience in stroke rehabilitation, including prior use of task-oriented training (TOT). These experts reviewed the tool for clarity, relevance, and cultural appropriateness, and confirmed that all items effectively assess clinicians’ familiarity with and application of TOT. (S1 in Supporting information- S2 in Structured Interview Questionnaire)

Before data collection, a pilot test was conducted to ensure the interview guide was clear, perceivable, and effectively addressed the research questions. The questionnaire was drafted and administered in English, the medium of instruction and clinical communication for all participants. Where necessary, interviewers provided Urdu explanations for technical terms to ensure comprehension. This pilot test involved three physical therapists with five years of clinical experience from September, 1^st to 10^th, 2022. Piloting of interview guide leads to minor adjustments in wording for clarity and precision. Questions covered TOT activities for post-stroke recovery, including upper limb, lower limb, balance, and cognition, as well as cultural/contextual factors and barriers. Each interview lasted approximately 50–60 minutes.

Member checking & credibility

To enhance trustworthiness, member checking was employed at two stages:

1. During interviews – Key responses were paraphrased and confirmed with participants in real time to ensure accurate interpretation.
2. Post-analysis – A summary of thematic findings was shared with six randomly selected participants to validate whether the identified themes accurately represented their experiences. Minor refinements were made based on their feedback.

Additionally, triangulation was employed by comparing findings across different geographic locations, experience levels, and institutional settings to ensure a well-rounded perspective.

Data analysis

Data were analyzed using Braun and Clarke’s six-step thematic analysis [25], involving:

1. Familiarization with data – Transcripts were read multiple times for immersion.
2. Initial coding – Line-by-line coding was conducted by five independent coders using an inductive approach.
3. Theme identification – Codes were grouped into emerging patterns.
4. Theme review and refinement – Inter-coder reliability was ensured through consensus discussions. Disagreements were resolved via majority voting or secondary review by an external qualitative expert.
5. Defining themes – Finalized themes were reviewed in relation to research objectives.
6. Report writing – A thematic structure was developed.

Use of ATLAS.ti9 for thematic coding

ATLAS.ti9 was used to facilitate systematic data organization, retrieval, and coding consistency [26]. Specifically:

• Coding was software-assisted, but final decisions were made manually to preserve contextual depth.
• The software was used to visualize code relationships, compare participant responses, and track co-occurring themes.

Ethical considerations

Researchers received training in qualitative research ethics, and the study was approved by the ethics committee. There were no pre-existing relationships between the researchers and participants before the study. Participants were informed about the study’s purpose and provided written informed consent before the interviews. They were also informed about the researchers’ qualifications and the study’s background during the consent process, but personal goals and motivations were not disclosed to prevent response bias.

Ethical approval: Riphah International University ethics committee Riphah/RCRS/REC/01424).

Participants

A total of 40 physiotherapists were invited to participate, of whom 22 physiotherapists met the inclusion criteria and consented to interviews. The participants had a mean clinical experience of 5.45 ± 0.59 years and an average age of 35.09 ± 2.81 years. The sample was predominantly male (68.2%), with 11 participants (50%) based in Lahore, followed by Faisalabad (22.7%), and smaller representation from cities like Peshawar, Rawalpindi, Jhelum, and Islamabad (Table 1).

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Table 1. Demographic characteristics of participants.

https://doi.org/10.1371/journal.pone.0330634.t001

Themes

Analysis of the interview data revealed six overarching themes, each comprising multiple sub-themes. Braun and Clarke’s thematic analysis was used to derive these themes inductively, and negative cases were specifically sought to ensure analytical depth. All 22 participants (100%) responded to each domain of the semi-structured guide (demographics; understanding and application of TOT; motor, cognitive, and balance training; barriers; cultural factors). The frequency of thematic responses is presented in supporting files. The themes include:

1. Task-Oriented Training (TOT) Practices
2. Motor Function Improvement (Upper & Lower Limbs)
3. Cognitive Rehabilitation
4. Balance Training
5. Challenges and Barriers in Implementing TOT
6. Cultural and contextual factors
7. Task-oriented training (TOT) practices

Majority of the participants 18 (82%) described TOT as a patient-centered approach integrating meaningful and functional activities into rehabilitation. They emphasized the need for functional relevance, patient engagement, goal-oriented approaches, holistic rehabilitation, and adaptability.

As one participant expressed

“TOT is not just about repetitive exercises. It’s about ensuring that patients can reintegrate into daily activities—reaching for a cup, standing from a chair, or walking on different surfaces.” (P8)

However, some physiotherapists expressed concerns about the lack of structured TOT protocols in Pakistan, leading to inconsistencies in practice. As one participant noted:

“There’s no standardized way we implement TOT here. Everyone adapts it differently, depending on their training and resources available.” (P12)

1. Motor function improvement for upper and lower extremities

Most of the physiotherapists 18 (82%) categorized motor function rehabilitation into upper and lower limb training, emphasizing both gross and fine motor skill enhancement.

Upper limb rehabilitation

Gross Motor Tasks: “We focus on larger movements first—reaching, lifting objects, and weight-bearing on the affected limb.” (P5)

Fine Motor Control: “For fine motor skills, we use object manipulation exercises, like buttoning a shirt or grasping small objects.” (P9)

Lower limb rehabilitation

Stepping & Gait Training: Physiotherapists incorporated stepping exercises on uneven terrain and stair climbing to mimic real-world walking conditions.

Negative Case: Some therapists reported limited patient adherence to lower limb training, particularly when early ambulation caused fear of falling.

“Many patients are hesitant to walk, fearing another stroke or fall.” (P14)

1. Cognitive rehabilitation

In current study, only 8 (36%) participants highlighted the critical role of TOT rehabilitation in enhancing cognitive functions among stroke survivors. This theme encompasses a range of activities and exercises tailored to improve specific cognitive skills. TOT was also used to enhance cognitive functions in stroke survivors, particularly attention, problem-solving, and memory.

• Attention Training: 7 (32%) therapists incorporated dual-task exercises that required patients to engage in mental calculations while walking.
• Quantitative Reasoning: “We sometimes use real-life tasks, like handling money, to improve reasoning.” (P3)
• Memory Retention: “We introduce games that require recalling names of objects or sequences.” (P17)

Negative case: Challenges in cognitive engagement

Despite the benefits, some therapists faced challenges in engaging patients with cognitive impairments, with low motivation and frustration reported as key barriers:

“Patients with cognitive deficits often struggle with task adherence. They get frustrated easily.” (P7)

Adaptation Strategy: Therapists found that breaking down tasks into smaller components and using visual prompts improved participation.

1. Balance training

Most of the participants 18 (82%) mentioned importance of balance training in integrating while giving task oriented training. Balance rehabilitation was divided into static and dynamic exercises.

• Static Balance: Included single-leg stands and tandem stance training.
• • Dynamic Balance: Included walking on uneven surfaces, obstacle navigation, and perturbation training.

Negative case: Resource Constraints in balance training

Many therapists cited the lack of specialized balance equipment as a limitation:

“We don’t always have access to balance boards or VR-based training, so we improvise with basic exercises.” (P11)

Resource constraints

• Limited access to TOT-specific equipment and funding shortages hindered implementation.

Negative Case: Some therapists reported that patients lacked access to rehabilitation facilities in rural areas, leading to sub optimal home-based rehabilitation:

“Many patients discontinue therapy because they can’t afford frequent travel to rehab centers.” (P16)

Time constraints

• Therapists struggled to balance patient loads with the time-intensive nature of TOT.

“TOT requires more time per session, but we have limited slots for each patient.” (P10)

Knowledge gaps & standardization issues

• Some therapists lacked formal TOT training, leading to variability in application.

Proposed Solution: Participants suggested structured TOT workshops to standardize implementation across clinics.

Patient-related barriers

• Cognitive impairments, fear of movement, and low motivation were major challenges.

Negative Case: A participant shared

“Patients sometimes don’t see immediate results, so they lose motivation quickly.” (P20)

Adaptation Strategy: Physiotherapists found that goal-setting, family involvement, and real-life task demonstration improved adherence.

1. Cultural and contextual factors

Current study explored the influence of cultural and contextual factors on the implementation of TOT in stroke rehabilitation. Participants highlighted several key factors that impact the process, encompassing four distinct sub themes: Cultural norms and values were highlighted by 12 therapists (55%). Healthcare system factors, including insurance limitations and urban‐centric services, were cited by 11 participants (50%). Socioeconomic factors, particularly work commitments and financial constraints, were reported by 10 therapists (45%). Finally, language and communication barriers were mentioned by 7 participants (32%), who emphasized the need for visual aids and non‐verbal instruction to ensure patient comprehension.

Cultural norms and values

Cultural beliefs shaped patient perceptions and rehabilitation adherence. Some patients prioritized traditional healing methods over therapy, leading to low engagement in TOT.

• Negative Case: “Many families believe rest and herbal treatments are better than exercise-based rehabilitation.” (P12)

However, integrating family members into therapy sessions improved adherence.

• Facilitator: “We train caregivers to assist with exercises, which increases compliance.” (P8)

Healthcare system factors

Limited rehabilitation infrastructure, urban-centric services, and lack of insurance coverage restricted patient access to TOT.

• Barrier: “Patients from smaller cities struggle to access physiotherapy services.” (P4)
• Barrier: “Many discontinue therapy because they can’t afford long-term sessions.” (P7)

Physiotherapists adapted by developing low-cost home-based TOT programs.

• Facilitator: “We create home-based exercises for patients who can’t afford regular visits.” (P17)

Socioeconomic factors

Financial constraints affected patient engagement and adherence to TOT.

• Barrier: “Patients often skip sessions because they can’t afford to miss work.” (P15)
• To address this, physiotherapists provided cost-effective modifications.
• Facilitator: “We teach exercises that require no equipment for home practice.” (P10)

Language and communication

Language barriers affected patient understanding and compliance with therapy.

• Barrier: “Patients from rural areas struggle with Urdu instructions.” (P19)

Physiotherapists used non-verbal communication and visual aids to bridge gaps.

• Facilitator: “Demonstrations and gestures help patients follow instructions.” (P9)

Impact and implications statement

• This study highlights how Pakistani physiotherapists adapt TOT in stroke rehabilitation, addressing barriers such as limited infrastructure, financial constraints, and cultural influences in low-resource settings.
• Findings reveal the underutilization of cognitive rehabilitation within TOT, emphasizing the need for integrating cognitive training into physiotherapy education and clinical practice to enhance patient outcomes.
• The study calls for standardized TOT protocols tailored to resource-limited settings and policy reforms to improve access to rehabilitation services, including financial support and structured therapist training programs.