Need & strategies for prioritisation of rehabilitation research in India

Materials & Methods

A comprehensive rapid literature search was conducted in scientific databases such as PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to report the current status of rehabilitation research in India (Fig. 1). The Medical Subject Headings (MeSH) categories and subcategories including India OR* Indian AND (rehabilitation research AND policy) (rehabilitation research AND system) (rehabilitation OR* therapeutic intervention OR* intervention) AND (physiotherapy OR* physical therapy OR* physiotherapist/s OR* physical therapist/s OR* physical therapy modalities OR* exercise therapy OR* group physiotherapy) AND (occupational therapy OR* occupational therapist/s OR* ergotherapy) AND (orthosis OR* orthotic devices OR* parapodium orthosis OR* braces OR* splints) AND (prosthesis OR* implants OR* artificial limb OR* replacement) AND (speech therapy OR* voice training) AND (audiologic rehabilitation OR* audiologic habilitation OR* aural rehabilitation) were used. Clinical trials registered in Clinical Trials Registry India (CTRI) and doctoral theses registered in Shodhganga were searched to identify rehabilitation research studies in India in addition to the articles published in scientific databases.

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Fig. 1.

Search strategy adopted in PubMed and CINAHL to search articles pertinent to rehabilitation from India.

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Papers describing research on rehabilitation, available in English since 1801 till 2024 were included. Articles reporting studies pertinent to rehabilitation services such as physiotherapy, occupational therapy, speech rehabilitation, audiologic rehabilitation, prosthetics and orthotics and clinical trials and doctoral theses pertinent to rehabilitation were included in the study. Filters such as systematic review, randomised controlled trials and meta-analyses were applied to ensure the inclusion of high-quality and evidence-based articles.

Two reviewers (RM and SK) screened the titles for inclusion. Queries were resolved with the third reviewer (QM). Studies belonging to other fields such as engineering, agriculture, economic, medical, ayurvedic or surgical were excluded. Findings of comprehensive rapid literature search were used to report the volume, spectrum of research and the level of research evidence in rehabilitation.

Results

A total of 10,692 and 546 research articles were identified in PubMed and CINAHL, respectively. Number of research papers, RCTs, or cohort studies conducted in India were substantially lower compared to the studies conducted in certain high-income countries (Table). An approach of bibliometric analysis is likely to change the precise number of published research articles.

Number of research projects registered with the Clinical Trials Registry India (CTRI) in the field of rehabilitation is also limited. Out of a total of 68,227 clinical studies registered in the past 17 yr (2007 to 2024), 1396 trials were identified after using a keyword ‘rehabilitation’; whereas the remaining studies were related to medical, surgical, ayurvedic, dental, unani and nursing interventions. All 1396 titles were reviewed and 365 studies were excluded, which involved medical, surgical or other complementary medicine interventions for rehabilitation. Among the 1031 rehabilitation clinical trials, 540 were randomised clinical trials; 133 were observational studies, 93 were cross-sectional studies and 265 experimental studies.

Another source of information on rehabilitation research in India was Shodhganga. It is a national reservoir of theses stored in a repository hosted and maintained by the INFLIBNET Centre. A search on Shodhganga with a keyword ‘rehabilitation’ revealed 164 theses between 1959-2024. On screening the titles, 55 theses were identified as relevant to rehabilitation whereas 109 studies were excluded, which involved engineering, agriculture, economic, medical, ayurvedic or surgical. Among the 55 theses, eight were observational, 12 were cross-sectional, seven were RCT, 16 were experimental and 12 others included case control, descriptive and mixed studies. Although it is possible that a few older theses may not have been uploaded on Shodhganga, the total number of doctoral studies in the field of rehabilitation remain low across India. Rehabilitation science does not feature in the top 20 areas of research on the current PhD research profile in India¹⁷.

Discussion

Our findings suggested that the volume and the level of research evidence pertinent to rehabilitation is considerably low vis-a-vis the huge and diverse need for rehabilitation services in rural-tribal and urban settings in India.

The strategies to prioritize context-specific rehabilitation research can be developed through either a top-down or bottom-up approach. It is possible to construct the steps at multiple levels ensuring harmonious action: (i) Macro-level: rehabilitation policy-makers, national rehabilitation research cell and government funding agencies; (ii) Meso-level: rehabilitation centres/institutes; (iii) Micro-level: rehabilitation workforce members (Fig. 2).

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Fig. 2.

Strategic framework for rehabilitation research in India.

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(i) Macro-level i.e. rehabilitation policy-makers, national research cell and government funding agencies: The two major challenges at the macro level are lack of national rehabilitation research framework and inadequate funding for rehabilitation research. India has demonstrated strategic planning, meticulous implementation and success in the immunization program and control of several communicable diseases such as HIV, tuberculosis, etc. in the past decades, resulting in a remarkable rise in survival¹⁸. However, rehabilitation research lacks a strategic framework. Design and implementation of an inter-disciplinary strategic research framework engaging various stakeholders of rehabilitation at multiple levels, is warranted to plan an effective rehabilitation research strategy for India with a defined agenda and time-bound output to address the unmet need of rehabilitation.

Recently, the World Health Organization (WHO) emphasised on promotion of high quality research in rehabilitation including health policy and systems research and proposed a research framework, through a multi-stakeholder participatory global consultative process in order to stimulate HPSR to generate the evidence required by key stakeholders¹⁹. In India, the existing rehabilitation research framework needs revived concerted attention of all concerned ministries, policy-makers, government funding agencies and national rehabilitation research cell with specific measures including (a) formation of a dedicated national rehabilitation research think tank for strategic advancement of rehabilitation research in India; and (b) allocation of dedicated research funding.

The think tank can be embedded into the existing national healthcare research framework, engaging the key stakeholders, namely - policy-makers and experts (engaged in planning, implementing, and budgeting rehabilitation services); rehabilitation educators (academic experts in designing and delivering rehabilitation education and cultivating inter-professional awareness about rehabilitation) and patients and caregivers (to share lived experiences and needs). Caregivers play a vital role in rehabilitation and hence they can have a meaningful voice in informing the research agenda including the socio-economic context in India. A participatory research approach with community-engagement and diverse stakeholders will result in an appropriate rehabilitation research agenda aligned with the national health research priorities and synched with the apex research body’s strategies for a Viksit Bharat 2047, alongside achieving the goal of rehabilitation for all²⁰. The think-tank would additionally monitor the execution of strategic rehabilitation research framework and timed tangible output, necessary for iterative recalibration of research agenda.

Currently, at the national level, research in various disciplines of medical science, biotechnology and science and technology is planned, supported and promoted by respective funding departments or councils such as Indian Council of Medical Research²¹, Department of Science and Technology²², Department of Biotechnology²³, etc. Research in complementary health sciences is promoted by the Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy Ministry²⁴. Each funding organization defines the research mandate of the respective organisation, which collectively informs the health research agenda for India. Currently, all the above mentioned research funding organisations which are funded by different ministries, such as Ministry of Health and Family Welfare²⁵, Ministry of Science and Technology²² and Ministry of Ayush²⁴, fund rehabilitation research projects in a fragmented manner. In the absence of a national strategic research framework, the rehabilitation research agenda is not in tandem. Hence, although rehabilitation research has been funded sparingly by all the above mentioned government funding agencies in India; proportionate funding with respect to the magnitude and complexity of rehabilitation need continues to be a challenge. For example, albeit the high incidence of trauma and fractures in India² or the common incidence of low back pain, the proportionate research focus is negligible²⁶.

Prioritised investment of government funding agencies in rehabilitation research in proportion to the need, can alleviate the socio-economic burden caused by limitations in functioning. It is expected that the efforts of National Commission for Allied and Healthcare Profession established in 2024²⁷ (including rehabilitation professions) would add impetus to rehabilitation research, in addition to the ongoing efforts of the Ministry of Social Justice and Welfare²⁸. Proportionate allocation of funding is essential for rehabilitation system research, policy research and implementation research to ameliorate the broad functions of rehabilitation such as awareness, early detection of impairment, intervention, improved functioning and monitoring²⁹.

(ii) Meso-level i.e. rehabilitation institutes providing training and service: The three major challenges at meso-level are inadequate robust research training in education, deficient research mandate with narrow focus of research limited to clinical research, and lack of monitoring of quality rehabilitation research.

At present, 822 institutes offer rehabilitation training and services in India, including 700 physiotherapy institutes, 27 occupational therapy institutes, 77 institutes offering training in audio speech therapy, and 18 institutes offering training in prosthetics and orthotics³⁰. The growing volume of rehabilitation institutes and service centres are addressing the need for training and service requirement in India³¹; but the gap in rehabilitation research remains unaddressed. The current the curriculum of most rehabilitation training programs includes research training in some form; but the implementation of research training is limited in scientific rigour. A large majority of rehabilitation institutes are yet to cultivate a culture of quality research and build a robust research ecosystem designed for context specific research.

Hence, it is essential to strengthen the research ecosystem at the institutes providing training and services including specific strategic measures as follows: (a) integration of appropriate basic research training into the curricula of all the rehabilitation education programmes and advancing the level of research training at higher academic levels, to achieve the competencies required to conduct quality research; (b) Planning a wide and diverse research mandate to cover the complete spectrum of research beyond clinical research; and (c) monitoring the implementation of quality research at rehabilitation institutes to achieve the expected output.

Emphasis on quality research training in all curricula of rehabilitation, at all levels (Bachelors-Masters-Doctoral) will help to build a critical mass of competent rehabilitation research taskforce in India. Currently, a total of 822 rehabilitation institutes, offer training across India, in a total of 783 districts (2024). It is possible for each rehabilitation institute to assess the rehabilitation needs of one or more neighbouring districts and build a context-specific research agenda. The collective agenda can provide insights into the health system research priorities and national rehabilitation research agenda in order to design need-based effective intervention strategies and address unmet rehabilitation needs of that particular district.

Secondly, a review of rehabilitation system including rehabilitation service provision, policies, cost of care, insurance coverage, and other components is important to understand the complete fabric of rehabilitation services in India and transform the rehabilitation landscape of India. It is also important that rehabilitation research needs to extend beyond tertiary care to primary healthcare to design effective strategies for achieving the goal of rehabilitation for all. The relevance and need for primary care research has been reiterated worldwide and few strategies to strengthen primary care research are available for reference³². Health policy and systems research will add value to the initiative of rehabilitation for all, by focusing on evidence for effectively organizing and integrating health services. It will also help to promote systems-thinking approach to meet rehabilitation need of all individuals for better health-outcomes¹⁸.

(iii) Micro-level i.e. rehabilitation workforce members: Only a small proportion of rehabilitation care professionals are engaged into research, resulting in limited research capacity within the rehabilitation workforce nationally. Based on the records available at the Shodhganga and the projects registered at the CTRI, it appears that out of a total of approximately more than 100 thousand qualified rehabilitation professionals engaged in either rehabilitation training or service^,33,34,35, a small portion is trained in research (doctoral level). The gap between rehabilitation research need and proportion of workforce engaged in research is wide.

Therefore, at the micro-level, there is an urgent need to strengthen the research capacity within the rehabilitation workforce members of all disciplines throughout India. Rehabilitation professionals engaged in training can be encouraged and motivated to conduct research on meaningful contextual research problems. The keen rehabilitation workforce members engaged in the service provision can be trained to review the services delivered for ongoing improvement³⁶. Measures to develop research competencies can include: (i) sensitisation and motivation of rehabilitation professionals with incentive and due remuneration for research efforts, and (ii) training professionals to acquire competencies essential to conduct context specific robust research.

The present review underscores the urgent need to prioritize context-specific rehabilitation research. India needs a strategic research framework for rehabilitation, which is built on permeable interaction between various divisions of research planning, funding and implementation namely health systems, health policies, health delivery, rehabilitation experts, and persons with rehabilitation needs and caregivers. Synchronised and iterative action at multiple levels responding to unmet rehabilitation need through a comprehensive strategy will produce the necessary momentum in rehabilitation research. The proposed strategies can inform appropriate action in countries with similar socio-economic challenges.

By examining the current research landscape and acknowledging the challenges, the analysis provides a roadmap for progress. The proposed strategic framework presents a comprehensive approach to prioritize, execute, and accelerate meaningful rehabilitation research across the complete spectrum of research including health policy and systems research. This will pave the way for accessible and effective rehabilitation services for all individuals in need across India, spanning urban, rural, and tribal communities at all healthcare levels. This framework holds the promise of using evidence to transform the lives of countless individuals with rehabilitation needs, empowering them to achieve their full potential and participate fully in society. By investing in rehabilitation research today, India can build a healthier and more inclusive tomorrow.