The study was conducted using the phenomenological method, a qualitative research technique. In the study, a semi-structured interview was used with a non-participant observation method. All interviews were conducted individually. During the semi-structured interview, the researcher not only asked the predetermined questions, but also asked additional questions that would elaborate the answers without directing the participants according to their answers. The researcher conducted the semi-structured interview not only by asking predetermined questions but also by bringing up interesting topics mentioned by the participants.16 Because the non-participant observation method was used in the study, the researcher only observed the participant and collected the data by taking voice recordings; otherwise, no intervention was made.17

A purposive sampling method was adopted, and physical therapists who have followed neurological patients with TR were included in the study. Before starting the study, approval was obtained from the Atatürk University Faculty of Health Sciences Non-Interventional Ethics Committee (decision no: 2024/03/15). Polkinghorne18 recommends that the researcher interview 5–25 participants who have experienced a particular phenomenon. In addition, qualitative studies show that sampling should be terminated when data saturation is reached, when meaning saturation is reached, and when repetition occurs.19 In this study, a total of 25 physical therapists who had experience in applying neurological rehabilitation through TR in our country were identified using national health databases and thesis archives. Physical therapists were informed about the study through various communication channels such as e-mail and social media. Interviews were planned with 15 physical therapists who agreed to participate in the study according to the order of contact. Data saturation guided the sample size for this study. When the interviews with eight physical therapists were completed, it was observed that data saturation was reached and the interviews were terminated at this point.20 Of these physical therapists, four monitored patients in Ankara, two in Izmir, and two in Istanbul. The participating physical therapists were five females and three males, aged between 26 and 36 years. Their professional experience ranged from 4 to 11 years. Two of the participants had followed two patients post stroke, two with PD, and four with multiple sclerosis. The participants performed TR sessions for durations ranging from 4 to 12 weeks (Table 1).

A total of eight semi-structured, in-depth interviews were conducted with eight physical therapists between March and May 2024. Each interview lasted between 30 and 45 min and was conducted in Türkiye. Documentation was done using field notes and post-interview notes. Written informed consent was obtained from all participants, and the data collected were securely stored with the removal of identifiers to protect confidentiality. The interview guides were designed based on previous literature and the researcher's expertise (Box 1).21,22

Braun and Clarke's six-step thematic analysis was used to analyze the data. The approach includes: (1) familiarizing oneself with the data through transcription and repeated reading; (2) generating initial codes; (3) searching for themes; (4) reviewing themes; (5) identifying themes; and (6) writing conclusions, including explanatory quotes.23 The interviews were transcribed and coded using the MAXQDA software version 2020.2.2. Once familiar with the data, B.Ö used line-by-line coding to analyze the initial transcripts and identify the main themes that emerged. Combining this inductive approach with previous literature and written notes, he developed a preliminary coding framework, which was finalized by the team.24 Thematic analysis was conducted within the categories of the coding framework, with constant comparison at different levels, between content, and code within an interview, between themes, and groups of themes.25,26 The team met regularly to discuss emerging themes. Saturation of codes and meanings was reached after interviewing 8 physical therapists.

Advantages-Accessibility: Many physical therapists in our study commented on the accessibility of TR. The most important opinions about accessibility were the elimination of the effects of weather conditions and transport problems. "Today it is rainy, today there is snow in the air, there is no chance for them to say, 'I will not come'. Therefore, they participate more easily …… In a different situation, for example, one of my patients would come and go from a distance of one hour by car" (P02).

Advantages-Flexibility: The flexibility of TR sessions was another advantage frequently reported by physical therapists. "When they had something to do, we could immediately change that time or day. We could plan it for another day. In other words, it is a method open to all kinds of manipulation so as not to change the treatment dosage" (P03).

Advantages-Comfort: Physical therapists stated that one of the most important advantages of TR sessions is the high level of comfort. "One of the most common things that patients say is the comfort in the home environment…" P02. "…He said that it was very comfortable for him to go home after work, eat his dinner, and then do online exercises" (P01).

Advantages-Less physical effort: One of the most important advantages that the physical therapists in our study emphasized was that the physical effort was less than in face-to-face sessions. "Those who came to face-to-face sessions usually came tired. Some patients even said, "Let me come half an hour early, let me rest a little in the clinic, then let's do exercises. Since telerehabilitation sessions are attended from home, this is not the case." P08. "They said that starting exercise before fatigue occurs is really efficient for them in terms of exercise. Because of the time they spent on the road, some patients with physical mobility disorders stated that they were extremely tired while coming to the clinic" (P06).

Disadvantages-Lack of physical contact: One of the main barriers perceived by therapists is the lack of physical contact with patients. In our study, physical therapists stated that this made it difficult to teach exercises to patients during the session, to receive feedback from patients, and to improve the patient-therapist relationship."The patient turns a screw during the treatment. I say, Look, now I want you to do this movement, ……, not just this movement. By touching the patient, I can explain something that I would explain in 10 s, without touching the patient, I can explain it in 1 min, I can explain it in 2 min" (P02). "I felt as if I had less control because I could not touch the patient. Of course, it is not possible in cases where I want to do manual application" (P01).

Disadvantages-Safety: Another situation that physical therapists who followed neurological patients with TR saw as a disadvantage was patient safety problems."When I mobilised the patients more actively, there were situations where I could not mobilise them, or rather, let me put it this way, when there was a loss of balance, I had to hold back from doing some things due to safety problems" (P05). "Another thing that is missing is patient safety. In order to ensure patient safety, it is necessary to provide a system for the patient. This is not possible. Therefore, it is a little difficult to ensure patient safety" (P02).

Disadvantages-Loss of session time: Physical therapists reported that they lost session time due to communication problems with patients during the session, internet interruptions, and freezes, and it was more difficult to explain exercises to patients online."I was explaining something that I could explain in 10 s in 1 min or even 2 min" (P02). "The internet coming back can cause temporal cost, so in this case, we actually lose session time" (P05).

Disadvantages-Failure to provide a standard environment: The disadvantage stated by some physical therapists is the difficulty of providing a standard rehabilitation area in the home environment of the patients. "The floor where the patients do their exercises can be different…. lighting can be different…Of course, there may be objects around, they can get stuck in the objects …. so the house is not suitable, again some features caused by the environment limit us in this case "(P04).

Suggestions-Strengthening the technological infrastructure: "I think it can be integrated with technology. In other words, technical infrastructure can be established, future studies can be like this, but these are really expensive things. They really need infrastructure and support. It can be integrated with virtual reality applications or consoles" (P03). Physical therapists applying telerehabilitation in neurological patients stated that it is necessary to monitor the patients instantly. "…patients can be evaluated instantly with wearable sensors, smart watches or other sensor-based technological devices. Because we cannot monitor the patient and we cannot physically intervene with the patient" (P04).

Suggestions-Simple interfaces specific to telerehabilitation: One of the most important recommendations of physical therapists is the dissemination of TR applications with simple interfaces. During the interviews, therapists frequently complained that patients had problems in connecting to the session. "We had problems in the connection part, so there should be simpler interface systems specific to TR. It can be combined with other technological possibilities" (P07).

Session decision making process-Pandemic: Most of the physical therapists in the study stated that they turned to TR as a necessity during the pandemic period. The most important reasons for preferring TR in this period were; they stated that it was safer for patients in that period and that hospitals were closed due to restriction decisions. "Since it was the pandemic period, we could not reach every patient. Patients would not be able to come to the hospital due to restriction decisions. Therefore, we planned the treatment as TR" (P01).

Session decision making process-Logistic: We can say that perhaps the most important effect of TR, especially by both patients and therapists, is that it eliminates transport problems. "…Of course, the fact that our patients come from many cities was also a factor. Although our centre was in Izmir, patients came to us from all over Turkey" (P05).

First impressions during the session-Inexperience: Physical therapists stated that because they had to adapt quickly due to the pandemic, both they and the patients experienced inexperience, especially in the first sessions of TR. "Since I was doing it for the first time, there was also an amateurism for me. Of course, I got used to it in a few sessions, but for example, all patients have some difficulty in the first two sessions, to be honest. But after three sessions, the patients started to do the exercises very easily" (P01). "The patient group that I applied the TR session was a group that experienced it for the first time. I was also experiencing it for the first time, so there was a lot of uneasiness" (P06).

First impressions during the session-Problems in compliance with the session: "Some patients looked at the screen themselves, sometimes the screen was looking at the ceiling, sometimes it showed the patient halfway, but I was following it somehow. I mean, the fact that the patients were a little unfamiliar with technology affected the process, of course" (P08). "The level of technology use of the patient is especially important here, patients whose technology knowledge is not very good had more difficulty in adapting to the TR session" (P02).

Problems during the session-Internet outage or poor internet connection: The most common problems during the session cited by physical therapists were internet outage and freezing or slowing down of the image due to poor internet. Physical therapists had to postpone sessions due to image freezing or slowing down. "If these freezes, image disturbances were happening a lot because I could not see the exercise, I could not understand whether it was fully done or not, I had to postpone the session" (P06). There were also physical therapists who had to change the exercise area during the session for the same reason. "There were freezes in a few patients. The modems were in the living room and the exercises were usually done in other rooms, but the problem improved when the patients changed rooms" (P01).

Problems during the session-Failure to connect to session: "I can state that some patients generally could not open the application we would use during the session" (P07) "There were many patients whose camera could not be opened. We solved them with video calling methods, such as allowing access" (P02).

Problems during the session-Lack of communication: Some physical therapists reported serious problems in communicating with patients. "Sometimes it is a little difficult for them to understand what is being explained. We experienced this a lot, especially in the elderly. In fact, one of my patients had a one-hour session. It was up to one and a half hours. The reason for this was difficulty in understanding" (P08).

Solution strategies-Training: Some physical therapists trained the patients on the interface to be used to avoid problems during the session and worked on scenarios during the session. During the interviews, many of the physical therapists mentioned the necessity of providing training to the patients on equipment, sessions, and other issues. "We installed applications on their computers. We taught them how to use them. How will they enter the password, ID? …… We gave a training on possible scenarios, for example, the internet went out. The camera is switched off. Where will they switch on the camera? Where will they connect the sound? We gave training on these." (P02).

Solution strategies-Relative or Caregiver Support: Many of the physical therapists who follow neurological patients with TR stated that the support of relatives and caregivers is very important and that they play a key role in solving the problems experienced during the session. "Some patients could not connect. We used to get support from the patient's relatives, and those who had no relatives with them used to get support from their neighbours" (P06). "We also asked the caregivers what we would do for each patient, what we expected from the caregiver, and if it was possible for the caregiver to be present in the session. We also trained the caregivers on some issues." (P02).

The most important limitation of ours is that the physical therapists who participated in the study followed patients in the three largest cities in our country and shared their experiences specific to the patient populations in these cities.

It is important for TR practitioners working in the field of neurology to remember that caregivers or family members are one of the most important stakeholders in TR sessions. For the sessions to be efficient, practitioners should educate both patients and caregivers about the TR system. Otherwise, there may be problems with communication and interaction with patients during the session. In addition, inexperienced patients may prevent the efficient use of the session time. Therapists in our study agreed that the technical infrastructure of TR systems should be improved, the systems should be developed in such a way that patients can be assessed, and patients should be monitored in real time. Overcoming the lack of physical contact should be the most important goal for future studies. In this way, patients can participate in sessions in a safer and more confident manner. In addition, the TR application area must provide all the necessary physical conditions for exercise. Therefore, a standardized TR-specific space should be created in patients' homes. Physical therapists state that it is almost impossible to perform advanced exercises in TR sessions, and there is a widespread concern that such exercises may lead to adverse conditions. Future studies should work on the solution to this issue.