Family-delivered rehabilitation services at home: is the glass empty?

In low-income and middle-income countries, meeting inpatient and outpatient rehabilitation needs of stroke survivors with insufficient staff and facility resources is especially challenging. Family-delivered rehabilitation services might be an innovative way to augment intensity of practice. 1 The ATTEND Collaborative Group's ATTEND trial, 2 published in The Lancet, is to our knowledge the first appropriately powered trial to investigate the effect of family-delivered, home-based rehabilitation intervention for patients with stroke in a low-middle-income country. In this prospectively randomised open trial with blinded endpoints conducted across 14 hospitals in India, populations with different languages, cultures, and health systems were assessed using the modified Rankin Scale (mRS), with death or dependency (mRS 3–6) at 6 months post stroke as a primary outcome. Patients were randomly assigned to receive additional structured rehabilitation training, delivered in three 1–h sessions in hospital and continued in up to six home visits for up to 2 months after discharge, or care as usual. The ATTEND Collaborative Group hypothesised that family-delivered rehabilitation services would increase independence and survival at 6 months after stroke. Unfortunately, the results of this pragmatic trial showed no favourable benefits when the proportion of disabled and deceased patients (285 [47%] of 607 patients) in the intervention group was compared with that in the control group (287 [47%] of 605 patients) at 6 months after stroke (odds ratio 0·98, 95% CI 0·78–1·23, p=0·87). Similarly, no surplus value was found in terms of secondary outcomes such as length of hospital stay, basic and extended activities of daily living, perceived anxiety, depression, and quality of life of patients and burden on their caregivers. These results render the ATTEND trial neutral, without any positive trends that would favour family-delivered rehabilitation services at home when compared with no therapy or a very limited number of sessions of outpatient care. The ATTEND Collaborative Group needs to be congratulated for this important, methodologically well conducted trial. The results of the ATTEND trial are in line with the cost-effectiveness of a structured inpatient training programme for caregivers after stroke, 3