Current Medical Issues

: 2017  |  Volume : 15  |  Issue : 4  |  Page : 285--287

Rehabilitation of stroke: A summary of the ATTEND study

Anna T Valson 
 Christian Medical College, Vellore, India

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Valson AT. Rehabilitation of stroke: A summary of the ATTEND study.Curr Med Issues 2017;15:285-287

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Valson AT. Rehabilitation of stroke: A summary of the ATTEND study. Curr Med Issues [serial online] 2017 [cited 2022 Dec 6 ];15:285-287
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Source: This is a summary of the study: The ATTEND collaborative Group: Family-led rehabilitation after stroke in India (ATTEND): a randomized controlled trial. Lancet. 2017 Aug 5;390. (10094):588-599. Summary prepared by Dr. Anna T. Valson, Christian Medical College, Vellore, India.

Clinical Question: Is family-led rehabilitation superior to usual care for stroke patients in a low-resource setting?

Authors' conclusions: (1) Family-led rehabilitation did not improve outcomes, but did not cause harm such as adding to caregiver burden. (2) The results of the study do not currently support the setting up of stroke rehabilitation services that shift tasks to family caregivers.

 Why this Study?

Stroke patients in developing countries such as India have limited the access to a multidisciplinary team of health professionals who can monitor and facilitate their rehabilitation after hospital discharge and provide much needed support to caregivers. Since the development of such multidisciplinary teams across the length and breadth of the country is not economically or logistically feasible, an attractive low-cost alternative is “Task Shifting,”[1] i.e., training caregivers to provide the needed physiotherapy to patients at home. The importance of this approach has been highlighted by the WHO in its Task Shifting Guidelines.[2] Although this is an approach that makes eminent practical sense and is scalable, there is very little evidence that it is effective in improving disease outcomes. This study [3] aimed to generate evidence regarding whether Task Shifting to family caregivers could reduce death and disability in stroke patients in India. A pilot study was carried out at Christian Medical College, Ludhiana, Punjab, to establish the trial methods,[4] and the protocol was published before data analysis of this study.[5]



Stroke in India

Stroke affects Indians around 15 years earlier than most developed countries. The mean age of the study participants was 57.5 years and 67% were maleThe spouse was the caregiver in 41% of cases, followed by sons/sons-in-law (29%) and daughters/daughters-in-law (22%). Only 1% used a hired help as caregiver and only 48% of patients had studied to high school level or above71% had a monthly household income 44% were diabetic, 74% were hypertensive, 76% had an ischemic stroke, and 56% were partial anterior circulation syndromesOn an average, stroke patients across the country receive only 2 h of physical therapy in hospital before dischargeIndian male stroke victims have a lower risk of death or dependency at 6 months compared to female stroke victims.

Study outcomes

There was no difference between groups in baseline characteristics such as age and gender composition, comorbidities, marital status, type of caregiver, type of residence, patient's education level, occupation, monthly income, and type and severity of stroke. Both groups received similar duration of routine hospital rehabilitation in hospital, though the intervention group practiced fewer mobility activities. In addition, the intervention group received around 3 h of training in hospital and an additional 3 h of training after hospital discharge. There was no difference in mRS or Barthel index scores between groups at hospital dischargeAfter discharge, the intervention group reported that patient and caregiver performed on average around 30 min of daily exercisesAt both 3 and 6 months, there was no difference between groups in death and dependency (primary outcome) or any of the secondary outcomes, including duration of hospital stay, rehospitalization rate, and adverse events. There was a nonsignificant reduction in deaths in the intervention group. There was no difference between groups in caregiver strain, anxiety, or depression. These findings remained robust across a wide range of statistical analyses.

Strengths and limitations

The strengths of this study include the randomized control trial design, large sample size with representation from all across India, comprehensive assessment of almost all aspects of stroke morbidity by a variety of well-validated instruments, and meticulous attention paid to training both coordinators and assessors across all centers. The procedures in place for blinding, data analysis and data safety monitoring appear to be robust, and the use of a pilot study to establish trial methods provide a high credibility factor.

The limitations are that the study was restricted to urban centers and may not be representative of the natural history of stroke in rural India. In fact, it is likely that such an intervention may be more effective in such settings where stroke patients often have no access to specialized care. It is also debatable whether 3 h of additional training in hospital and a further 3 h of training after discharge are sufficient to transfer the required rehabilitation skills to caregivers in a country like India where there are vast socioeconomic and educational inequalities. The time that patients and caregivers in the intervention group spent in performing physiotherapy daily (30 min) was much less than what is traditionally followed in most developing countries (1–2 h). Thus, the intensity of the postdischarge intervention may not have been enough to bring out differences between groups sufficiently. In addition, it is likely that caregivers may have benefited from a more task-oriented approach to training rather than one that had multiple components including information provision. The efficacy of the intervention could also be influenced by family dynamics, and the use of nonfamily health workers such as Accredited Social Health Activist workers may have produced better results, though at the risk of increasing the cost of intervention. The study did not report the health economic outcomes related to the study (the authors have stated that this will be the subject of another publication), which may have been able to show benefit to the intervention group in terms of reduced direct or indirect medical costs.


The study did not show any difference in terms of death, disability, and various physical, emotional, and quality of life indicators at 3 or 6 months between patients who received usual care and those who had a family nominated caregiver trained to provide rehabilitation services at homeIt is interesting that the intervention did not increase caregiver burden because caregiver burnout is a very significant factor that comes into play in chronic disabling conditions. This is a positive outcome, even though it may not receive much attention. We await the results of the health economic analysis of this study to come to a conclusion regarding whether family-directed rehabilitation services have any future in a low-resource settingFurther research is required to determine what particular aspects of caregiver training could result in an improvement in post-stroke death and disability outcomes, whether tasks should be shifted to nonfamily health-care workers or community-based teams, and also the social, behavioral, and economic factors that determine stroke outcome.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task shifting for non-communicable disease management in low and middle income countries – A systematic review. PLoS One 2014;9:e103754.
2WHO. Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guidelines. Geneva: World Health Organization Press; 2008.
3ATTEND Collaborative Group. Family-led rehabilitation after stroke in India (ATTEND): A randomised controlled trial. Lancet 2017;390:588-99.
4Pandian JD, Felix C, Kaur P, Sharma D, Julia L, Toor G, et al. Family-led rehabilitation after stroke in India: The ATTEND pilot study. Int J Stroke 2015;10:609-14.
5Alim M, Lindley R, Felix C, Gandhi DB, Verma SJ, Tugnawat DK, et al. Family-led rehabilitation after stroke in India: The ATTEND trial, study protocol for a randomized controlled trial. Trials 2016;17:13.