Essential neurorehabilitation in the aftermath of COVID-19

The impact of coronavirus on our health service has been highly documented, but with the first wave passed, the burden has not lifted, but altered, in the form of rehabilitation.

Earlier this week, we highlighted an article in Reuters which has since been echoed in multiple publications – the long-term implications of COVID-19 on a recovering population are huge. Dr Helen Salisbury, general practitioner and BMJ columnist, tweeted last week that 1 in 10 patients recovering from COVID-19 are experiencing prolonged symptoms.

Now that the first wave is receding, the patients who need our attention are the estimated one in 10 with prolonged symptoms.
Helen Salisbury: When will we be well again? https://t.co/benuge48NA

— Dr Helen Salisbury (@HelenRSalisbury) June 23, 2020

Healthcare practitioners and researchers alike are highlighting the widespread impact of the disease on those who have been affected, and are now trying to recover. Just under 270,000 people have contracted COVID-19 and made a recovery here in the UK, but the difference between recovery and returning to health, for many, is significant.

GP Sarah Jarvis reported to the BBC back in May that recovery from respiratory difficulties could take two to eight weeks, with tiredness continuing beyond that. Short videos became available online from medical practitioners seeking to assist in rehabilitation, with some specifically detailed proven relief from COVID-related respiratory distress. At this time, the extensive impact of COVID-19 on other organs around the body was little known.

Neurological implications

Neurological components to COVID-19 have been highlighted recently, with symptoms including delirium and confusion. A recent study of 153 younger patients treated in UK hospitals during the acute phase of the COVID-19 pandemic describes a range of neurological and psychiatric complications that may be linked to the virus. The study, carried out by the Royal College of Psychiatrists, is one of several over the past months drawing necessary attention to the neurological, cognitive, and emotional implications of the coronavirus pandemic, and COVID-19 disease.

Recent evidence also focuses on the longer term implications for those neurological symptoms. The Neurological Alliance, in their latest report to the Health and Care Select Committee, stated:

‘It now appears that a significant percentage of people with COVID-19 in ITU (maybe up to 35% of cases (Mao, 2020)) have some neurological symptoms, including being at an increased risk of stroke and functional neurological problems.’

This increased risk suggests additional strain is likely to fall on already stretched neurological services in the aftermath of this pandemic.

In addition to this burden, those who have experienced COVID-19 whilst already living with a neurological condition may have seen a deterioration in their existing condition, or exacerbation of their existing problems, through the impact of coronavirus.

The Neurological Alliance’s report highlights, not only the additional challenges likely to face those with a neurological condition who have contracted COVID-19, but the challenges that already faced them in accessing the right services in a timely fashion before the pandemic had such a profound effect on the NHS’s way of working, and capacity to support those in need.

Services which were already struggling to cater for demand must now support an increasing number of people in recovery, whilst maintaining social distancing, utilising virtual clinics, digital solutions and telemedicine - something in its infancy within the NHS. This form of interaction can also cause particular challenges where physical assessments are needed, or for therapists who employ hands-on treatment.

Mental health implications

The BBC have recently brought together a wealth of emerging evidence, not just on the physical health implications of this pandemic, but the long term implications for family life, long term mental health, and ongoing emotional and cognitive difficulties.

Stating that ‘roughly one in five people who pass through intensive care in normal times go on to exhibit symptoms of post-traumatic stress disorder (PTSD)’, the article also cites the level of delirium experienced in the ITU over the past months. With some patients still experiencing that delirium weeks after their discharge from ITU, it is unclear whether this is owing to their experience of illness in intensive care, or the neurological symptoms of delirium associated with COVID-19.

Kate Tantam, a specialist rehabilitation sister in intensive care at University Hospital Plymouth NHS Trust, shared that delirium "is the key link to post-traumatic stress, anxiety and depression" among people who survive their time in intensive care. She suggested that mental health difficulties arising from the stress of the pandemic, and of lockdown, may be just the beginning of the rehabilitative burden to mental health, another component of our healthcare challenge today.

Eight weeks into lockdown the Royal College of Psychiatrists warned of the coming ‘tsunami of mental illness’. Now, a new report from the Centre for Mental Health shared projections that ‘about half a million more people will experience a mental health difficulty over the next year’ as it predicts the mental aftermath of the pandemic.

The more data that emerges, the more significant - and overwhelming - appears the task before us. It is clear that our health and social care services are at the very beginning of their task to meet a growing need in both physical and mental health, as the nation begins to rehabilitate.

References

• Ling Mao; Huijuan Jin; Mengdie Wang et al, Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China, JAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1127. Accessed here: jamanetwork.com/journals/jamaneurology/fullarticle/2764549, 1 May 2020.
• Neurological Alliance: ‘Submission to Department of Health and Social Care Inquiry into Delivering core NHS and care services during the pandemic and beyond’ 7th May 2020
• The Centre for Mental Health, ‘COVID-19 and the nation’s mental health forecasting needs and risks in the UK’

→ Watch our MS Academy webinar from 1 July 2020: Neuro rehabilitation – now and the future