New Delhi: Family-led rehabilitation among stroke patients is ineffective, a randomized controlled trial report published in the Lancet has revealed.

The trial called ATTEND, conducted by the Indian Institute of Public Health and the George Institute for Global Health along with other international universities, showed that there was no reduction in disability for patients on the trial, compared to those who received no extra care.

The George Institute researchers, both in India and Australia, along with international and Indian stroke experts followed 1,250 patients over six months in India, where stroke affects much younger working age people than those in high-income countries (an average of about 15 years younger). Half of the patients were provided with access to professionals, such as physiotherapists, who taught the family techniques such as mobility training and communication practice. Each patient was also visited at home to ensure the rehabilitation was carried out correctly by the caregiver.

The intervention more than doubled hospital therapy time, provided additional community training and was associated with about 30 minutes of daily therapy-related activities by the patient and caregiver in the first month at home.

“We had expected to see a marked improvement in recovery of people who received this extra care delivered by their own trained family members, in their own homes. We found that despite extensive training in hospital and during follow up visits in the home, there was no difference in the degree of recovery or quality of life of people who received this extra treatment," lead author, Richard Lindley, professor at The George Institute for Global Health, said.

“Our results suggest that effective rehabilitation may need to be provided by professionals who have undergone years of training and are specialists in their own field, which may impose major challenges to poor communities with limited financial resources," he said.

The results raise serious questions about the benefit of rehabilitation carried out by family members and highlight the need for urgent investment in professional stroke facilities in low- and middle-income countries such as India. “In India, there are only 35 stroke units across the whole country, and most are in the cities. In response to the rising rates of stroke there needs to be much greater investment in facilities for people affected by stroke, and measures to protect them from the potentially prohibitive costs of treatment," Lindley added.

Across the world, it had been hoped medically that family-led care—also known as task shifting (the training of non-healthcare workers to perform tasks traditionally undertaken by the multidisciplinary team)—would help address the limited healthcare access for those with stroke in low- and middle-income countries. Community rehabilitation is also a priority of the World Health Organisation (WHO).

The results of the trial provide important new evidence that task shifting a complex intervention such as rehabilitation may not be effective. “Task shifting is increasingly seen as a solution to targeting chronic diseases in many countries in the world. But our results show it may be ineffective for some conditions and waste already limited resources. We need more rigorous examinations of such family and community led programs before they become commonplace," G.V. Murthy, professor at the Indian Institute of Public Health and the co-chair of the study, said.

It is estimated that around 1.6 million people have a stroke in India each year, yet the vast majority receive no formal rehabilitation. Stroke research in India has recently received new funding from the Indian Council of Medical Research (ICMR).

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