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Rehab’s new wonder drug?

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When Ava Twomey was diagnosed with a rare form of epilepsy as a
baby her parents were told she’d never walk or talk – and might not live beyond the age of three. She would also be in residential care for the rest of her life, experts said.

Now aged seven, Ava (pictured) not only walks, but can dance, and loves chatting, mostly about Red Riding Hood.

“She’s even started getting an attitude,” says her mother Vera, who attributes her daughter’s remarkable progress to cannabis.

Her case has added fresh momentum to the push to legalise medical
cannabis – in her native Ireland
as well as the UK – for
people with debilitating
brain conditions.

Ava has Dravet syndrome, a catastrophic, lifelong form of epilepsy that begins in 
the first year of life with frequent and/
or prolonged seizures.

It can be life-threatening and severely life-limiting
- causing numerous challenges including developmental delay, movement, balance and growth issues, chronic infections, body temperature regulation problems and orthopaedic conditions.

Vera, who lives in Cork with her husband Paul and three other children, says: “We were in a very dark place with our daughter and her life was in danger on a daily basis. She could have six or seven seizures together and we didn’t know if she’d wake up.”

In the darkest chapter, Ava (pictured) suffered a heart attack brought on by the severity of her seizures, and spent eight days in a coma.

The turning point was the
discovery that medical cannabis 
could do what many other drugs had
failed – hold off Ava’s seizures.

“Ava had been experiencing about 20 tonic-clonic seizures [causing stiffening, rhythmic shaking and unconsciousness]. She could have a hundred absence seizures on top of that so she was staggering from seizure to seizure, never recovering before the next one came along. We would be in and out of hospital and Ava essentially spent every winter there.”

In October 2016 Vera discovered CBD
oil, a legal, non-psychoactive compound of cannabis.

“The difference was like being on another planet,” she says.
Over three months, Ava would normally have had around 500 tonic-clonic seizures. In the first three months with CBD, she barely had 20. As time passed, however, seizure levels began to creep back up.

“Dravet is a wicked condition in that it navigates its way around whatever medication is put into the body to bring the seizures back.”

The Twomeys then began reading about epilepsy treatments with THC, the principal psychoactive component of cannabis.

While CBD is legal in the UK, THC is not – as is the case in Ireland, save for one or two hard-fought exceptions.

Vera and Paul campaigned for three years to get THC treatment for Ava, with Vera walking 300km from her home to the Irish parliament to highlight the plight of children like Ava.

Eventually the couple took Ava to Holland last summer to access the treatment there and, after showing huge improvement,
were granted a special licence by the Irish government in November 2017.

“The government would probably say the decision was because we provided answers in the drugs trial, but in reality it was probably because there was a groundswell of support for Ava. There was a lot of anger in Ireland that a sick child should have to go to another country to get treatment.

“When the THC was introduced, the change in Ava’s cognitive ability was absolutely staggering. Words started to come more often and her balance improved. These things started with CBD but accelerated
with the THC.

“Since June 2017, the tonic-clonic seizures have entirely gone. That in itself is staggering. In terms of seizures now we just have to worry if her temperature gets high and she might give out a little shout and shake for a few seconds and then she’s back with us. That’s about as bad as it gets.”

Ava takes CBD oil alongside the THC product – effectively cancelling out the psychoactive element of THC.

“The CBD prepares the body for the THC, which does not result in her being high or stoned. Ava takes her medication
and is well, coherent and balanced. There are massive side-effects, but every side-effect is positive.

“She has better balance, better sleep, better appetite, clearer eyes, she’s more engaged and the seizure control is extraordinary. She’s also pain free and is going to school more often.

“She is a very happy little person, but she’s had a very painful life. Now that things are under control, she plays more with jigsaws and Lego and likes to dance, which she couldn’t do before. She loves Little Red Riding Hood, so to hear her say ‘what big eyes you have’ recently was extraordinary.

“I wish with all my heart that we could
have introduced these treatments to Ava when she was 18 months old. We could
have stopped the seizures, which have done significant damage to her brain. She will improve and she will get better, but if the damage hadn’t been done we could have brought so much more out of this child.”

Vera believes the UK, Ireland and indeed 
any other nation where medicinal
cannabis is illegal, should look to emulate the Netherlands.

“It was the most amazing experience to see doctors in Holland that actually listen to you. Nobody listened to us in Ireland. My understanding from talking to parents in the UK is that nobody is listening to them either about cannabis. There is such opposition to even talking about it.

“In Holland they were saying ‘you’ve tried 11 different forms of epilepsy medication. It is logical that you would then try CBD and THC for Ava’s seizures. You have tried everything else. It has been proven to work’.

“I couldn’t understand how neurologists in Holland are qualified to the same degree as neurologists in England or Ireland. They are each other’s peers. Yet only in Holland could they see the logic of treating such a catastrophic form of epilepsy with medical cannabis because the risk was so low and the chance of getting positive results would be so significant to the improvement in the child’s life.

“I can’t understand why neurologists in England and Ireland can’t look to Holland and engage with the neurologists there and emulate their empathy and professionalism and experience.

“They have such a wonderful system there that I don’t know why doctors
in England and Ireland aren’t rushing to
be engaged with them for the sake of
their patients.”

To date only three special licences like Ava’s have been issued in Ireland.
In the UK, the case of Alfie Dingley could open the door to legalisation.

Parents of the epileptic six-year-old have issued a petition with 370,000 signatures to Number 10, calling for access to medical cannabis.

It remains to be seen whether this is enough to shift a fairly deep-rooted government stance against legalisation. Some political figures are hopeful, however.

“I am more optimistic than I ever have been,” says Baroness Meacher (pictured), chair of the UK All-Party Parliamentary Group
for Drug Policy Reform, which recommends decriminalisation of drugs.

The life peer has been a prominent, crossbench voice of support for medicinal cannabis legalisation.

In recent years she has led a House of Lords debate on drugs policy and contributed to influential reports on
the issue.

She says: “It’s very interesting that Jeremy Corbyn has consistently made it clear that the Labour Party supports legalisation of cannabis for medicinal use. This is the first time that a major political party has made that position abundantly clear.”

Further optimism comes from the handful 
of Conservative MPs straying from the party line that the government has “no intention” of legalising cannabis as it considers it as “not having any medicinal benefit”.

“We have six Conservative party ministers, 
in the home affairs department and the Department of Health, all supporting the need for Alfie Dingley to have cannabis medicine to alleviate his absolutely
appalling seizure rate.

“So six ministers in
this government all accept that cannabis 
has been a remarkable medicine for this particular child.

“Once you have that recognition…and the neuro-paediatrician in the Netherlands believing that, with a tiny bit more THC, Alfie could improve further, then it is actually unsustainable to have cannabis classified within Schedule 1, which defines dangerous drugs with no medicinal value.

“Even if cannabis only helped one child as a medicine, that would refute its Section 1 position, so it should be moved out of that definition.”

Officially at the time of writing, Home Office ministers are “exploring every option” for Alfie Dingley, following a meeting with his family.

According to reports, a three-month trial led by Alfie’s doctors and based on sufficient and rigorous evidence” could be in the offing.

Baroness Meacher (pictured) suggests research is merely being used as an excuse to avoid or delay addressing the growing calls for legalisation.

“Home Office officials are clearly worried about recognition of cannabis as a medicine because they would have to change the schedule.

“They are demanding that Alfie is granted a licence for research purposes only, but the research population would be one and you would have no control group. It is a complete fig leaf I’m afraid and that is the sticking point – they will only agree to a licence if the child is seen as a research object.

“My impression is that ministers seem very open to getting on with things but they feel hamstrung by their officials.

“The evidence is now so strong and we have opened this up with ministers through the Alfie Dingley case. I think this is now the beginning of a new debate in parliament and we need to pursue it.”

The former social worker sees pressure mounting on the government from all angles, with many sources urging it to soften its stance.

Major charities like the Multiple Sclerosis Society are among those lobbying for change, with a survey it conducted suggesting that 72 per cent of people with MS support legalisation for medicinal purposes.

Others include spinal injury organisations and support groups for people with anxiety.
Even traditionally Conservative-leaning newspapers are on board, says Meacher, pointing to a recent supportive article in 
the Daily Mail on a young rheumatoid arthritis sufferer whose life was transformed by cannabis.

“Things are definitely shifting in a way they never have before. We know 74 per cent
of the public agree that cannabis should 
be regulated and legalised for medicinal purposes. So public opinion would be 
behind the government if they were to change things.”

Stephen Murphy (pictured), who consults on Europe’s legal cannabis industry, believes it will be financial implications – if anything – that change the current government’s approach.

“The UK argument is going to be economic,” says the co-founder of Prohibition Partners, which advises entrepreneurs, businesses, investors and regulators about legal cannabis markets.

“Unfortunately the social and health 
aspect, that sees hundreds of thousands of patients actually using this in the UK daily, hasn’t seemed to have had any influence
on the political establishment.

“The current government hasn’t shown any intent on 
the back of the social or health perspective so I believe the motivation will come from economics. It is going to come down to financials. How much can this save the NHS and how much can this make 
the exchequer?”

Britain’s economy already benefits from medicinal cannabis; the UK is the world’s largest producer and exporter of legal cannabis for medical and scientific use, figures from the UN’s International Narcotics Control Board show.

In 2016 the UK produced 95 tonnes of legal cannabis – 44.9 per cent of the world’s total.
A significant portion goes towards a cannabis-based medicine called Sativex, produced by GW Pharmaceuticals.

It is available on prescription for patients such 
as those suffering the effects of multiple sclerosis, but only on the NHS in Wales.

Murphy says: “One of the biggest cannabis production companies in the world is based here producing one of the leading global cannabis products. It’s ridiculous that we can’t treat UK patients with it.

“This industry can give life to towns or cities that have struggled. It is unlike any other because, even though it is an emerging and pioneering industry, we already know what the demand is, we know its usage and the value of it, so there is a lot of guesswork taken out of it.

“The big companies all have evidence of how this could be turned into potential business for the exchequer.”

If money is to be the motivator for legalisation, the UK may look to follow Germany’s lead. Since medical cannabis was legalised in April 2017, work has been underway to breathe life into a burgeoning industry.

“Germany wants to create its own domestic cannabis industry where production comes from Germany. Currently they import from Canada and the Netherlands but there are a number of producers bidding for licences to produce and supply domestic cannabis within Germany. That would allow them to control and monetise it, and create jobs.

“A lot of governments see medical cannabis as a way of boosting their pharma and agricultural industries. They want to position themselves as leaders in understanding how big and how widely used medical cannabis will be.”

The UK might also learn from teething problems being experienced in Germany as legalisation beds in; although Britain’s already-established production capacity gives it an advantage.

“If you want to import medical cannabis to Germany, you can only get a licence for one batch at a time. There are also limitations with the quantity, volume and variety of what’s being imported.

“Every batch needs to be improved to allow the patient to get a proper understanding of the consistency of the medicine, which may change depending on what’s available.”

There are also inconsistencies in prescriptions.

“The gatekeepers are the doctors but, where one might prescribe medical cannabis, another will not. A huge job needs to be done to educate them on the benefits and to tackle the stigma that they don’t actually know anything about it and so are not confident enough to prescribe it.”

Currently medical cannabis is legal in 12 European countries, with each market relying on its own laws in the absence of any Europe-wide legislation or guidelines.

“How it is implemented in Germany is very different from in Poland, Denmark or Italy, 
for example. Each state is deciding how best it fits their medical system. While Germany
is implementing it straightaway into the health system, Denmark is taking a four-year research and development approach to better understand where it can be applied.”

Closer to Westminster, the Channel Islands are in the early stages of legalisation.
Jersey and Guernsey have taken their
own stance on cannabis as self-governed 
isles outside the UK but British Crown dependencies.

Unlike the UK government, the Channel Islands are keen to import, grow and distribute medical cannabis.

Supply issues and legislative challenges are currently being grappled with. A January vote in the Welsh Assembly, meanwhile, saw a majority back calls for cannabis for medicinal uses to be legalised.
In Northern Ireland too, progress is afoot.

Billy Caldwell, an 11-year-old from County Tyrone with life-threatening epilepsy, last year became the first person in the UK to be prescribed medicinal cannabis.
Could such developments influence change at Whitehall?

“Places like Jersey, Guernsey, Stormont and the Welsh Assembly can all form together
to put greater pressure on centralised government to reform.”

This pressure, and the prospect of a “really exciting and sophisticated cannabis industry in the UK”, gives Murphy optimism that a UK legislative change will happen at some point.

How soon, however, could depend on the continual presentation of irrefutable evidence and the stubbornness of patient families like the Twomeys and Dingleys.

Cannabis and neuro-rehab: The facts

The All-Party Parliamentary Group for Drug Policy Reform (APPG) published an official report into cannabis in 2016 – featuring a number of conclusions relevant to neuro-rehab.

Eighteen months on, its author, consultant neurologist professor Mike Barnes, insists its findings – that cannabis
does indeed have medicinal benefits – should be heeded by
UK lawmakers.

He says: “It is essential that cannabis is legalised for medical use in order to alleviate suffering of those with pain and spasticity in neurological conditions.

“Legalising it will help many thousands of people in the UK, not just with neurological conditions but for other challenges including mental health and gastrointestinal problems.”

The findings of the report included:

  • There is good evidence to show that cannabis, including the non-psychoactive component CBD, can help to treat chronic pain, spasticity, nausea and vomiting and anxiety.
  • Cannabis products nabilone, dronabinol, nabiximols and smoked marijuana have all been shown to be efficacious to varying extents in a variety of pain settings in good quality studies.
  • Moderate evidence shows that it helps to stimulate appetite, which may also be relevant to neuro-rehab units.
  • There is good evidence for the efficacy of the cannabis extract nabiximols for reducing patient-reported spasticity symptoms, although there is not firm evidence for improvement in objective measures. There is good evidence of safety in the long term and for continued efficacy.
  • There is moderate evidence for the efficacy of oral cannabis extract for reducing patient-reported spasticity scores.
  • CBD has been shown to reduce anxiety whereas THC, the psychoactive part of the drug, usually has the converse effect.
  • Overall, there is good evidence for CBD use in anxiety. This evidence base includes a double-blind, randomised, placebo- controlled clinical study led by Bergamaschi in 2011. It showed that orally-administered CBD was associated with a significant reduction in anxiety, cognitive impairment, and discomfort in patients suffering from generalised social anxiety disorder subjected to a simulated public-speaking test.
  • There is a theoretical basis to suggest that cannabis could have implications for epilepsy. While animal model and early human studies are promising, however, at the moment robust trials are lacking but further results are awaited.

There is a theoretical basis to suggest that cannabis could provide neuroprotection in the context of traumatic brain injury, but as yet, evidence is limited and unconvincing.

Is there a risk of schizophrenia?
The perceived link between cannabis and schizophrenia 
is one of the most compelling arguments against the general legalisation of the drug.

Some parents who have seen their children descend into psychosis after taking cannabis over a prolonged period understandably oppose legalisation. Others believe regulation would stop young and vulnerable people accessing particularly potent or dangerous products.

According to the APPG for Drug Policy Reform’s official report, most literature supports
a causal hypothesis between cannabis use and psychosis, particularly if usage starts at an early age and if the individual has a genetic predisposition to psychosis.

But it is unlikely that any one environmental factor (such as cannabis use) or any one gene can cause schizophrenia on its own.

It appears that cannabis is 
a component cause in the development of symptoms of schizophrenia and the onset of this mental illness depends upon many interacting factors.

However, it is also worth noting that most people who use cannabis do not develop schizophrenia, and most people with schizophrenia have never used cannabis.

It
is likely that THC is the main cannabinoid which triggers schizophrenia and psychosis.
CBD, on the other hand, is known 
to be anti-psychotic and may
 have a therapeutic role as an anti-psychotic agent although further studies are required, the report says…

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There’s a ‘dire’ need for more VR rehab studies, researchers argue

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Researchers analysed twelve studies that looked at VR-enhanced rehab, and concluded it can offer long-term positive outcomes for patients with traumatic brain injuries (TBI), especially those with motor skills and cognitive deficits, and those experiencing difficulties with their balance.

One of the benefits of VR rehab is that it can provide a safe environment for people to practice skills with minimal risk of harming. Some VR platforms, the paper states, can model almost any type of environment that may be useful for rehabilitating motor skills including walking, balancing and moving on different types of terrain.

The researchers, from the College of Public Health at the University of Kentucky, US, looked at six studies that examined gait and balance. All six of the studies showed that VR-enhanced rehab made moderate improvements to TBI patients’ gait and balance.

The four studies researchers looked at that around VR’s effect on upper limb functioning was more limited, and drew mixed conclusions. The use of VR to enhance cognitive rehab had the least amount of supporting evidence. The six studies the researchers looked at measuring VR and cognitive rehab found limited evidence.

The researchers state that their review not only provides helpful data, but also shows the gaps in research. They concluded that their findings highlight a need for more research that can inform providers, policymakers and the public to draw conclusions about the effectiveness of VR-enhanced rehab, especially around newer, immersive VR-enhanced rehab.

“VR-enhanced rehabilitation has been utilized for almost two decades, yet data regarding its clinical effectiveness remain limited by multiple lower quality studies,” the paper states.

“This lack of data impacts the generalizability of findings and conclusions about such important factors as physical effectiveness, motivational improvement, and cost-effectiveness that healthcare providers, policymakers, and the affected public are able to draw.”

There needs to be more research in this area as newer VR tools become available in rehab, the researchers urge, to better understand how VR can help neuroplasticity, which is the brain’s ability to learn new things by making new neural connections.

“With the advent of newer generation VR tools utilising 3D visual and auditory stimuli such as mixed reality (MR) and immersive VR platforms, new hypotheses can be tested with the Hebbian theory of neural plasticity concepts at their core,” the study states.

Studies, the researchers say, now need to adapt to include more advanced and improved technology, which will allow new opportunities for clinical rehab.

“For example, in a healthy population, improvement potentials were found in balance and visuo-motor reaction time after MR action game play,” the study states.

There is a ‘dire need’ for future studies to improve the current understanding of the potential for VR-enhanced rehab, the researchers state. This is particularly the case in the US, whose healthcare system underperforms or ranks lowest across multiple health outcomes, including access and cost-efficiency, compared to other developed countries.

“Although we must be cognizant of the potential for initial higher costs associated with the purchase, maintenance, and staff training of some of these VR platforms to be incurred, many VR platforms could actually help provide more cost-effective care,” the paper states.

The researchers argue that more broadly available commercial VR systems could avoid altogether the need for more costly interventions.

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Virtual rehab “effective” for stroke recovery, research shows

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Since the beginning of the pandemic in March, therapists  have adapted face-to-face services to comply with social distancing measures. While many patients and practitioners alike seemed to adapt well, now research has confirmed that it can be a practical way of delivering rehab for stroke patients.

A new paper, co-authored by Brodie Sakakibara, assistant professor at the Centre for Chronic Disease Prevention and Management has found that remote, virtual rehab works for people recovering from a stroke.

Six clinical trials were launched across Canada as part of a Heart and Stroke Foundation initiative, where people recovering from a stroke were given interventions including memory, speech and physical exercise training.

Researchers from each of the six trials found that the telerehabilitation was just as cost-effective as traditional face-to-face rehab, and that patients mostly reported that they were satisfied with their telerehab.

They reported in the paper, published in the Telemedicine and e-health journal, that patients were most satisfied, the researchers found, when there was some social interaction and clinicians were appropriately trained.

Overall, clinicians reported that they prefer face-to-face interaction, but will use telerehab where this isn’t possible.

“Telerehabilitation has been promoted as a more efficient means of delivering rehabilitation services to stroke patients while also providing care options to those unable to attend conventional therapy,” Sakakibara says.

“These services can be provided to remote locations through information and communication technologies and can be accessed by patients in their homes.”

The researchers also highlight a need for technology in stroke rehab to be easy to use and well suited to the user’s needs.

“The older adult of today, in terms of technology comfort and use, is different than the older adult of tomorrow,” Sakakibara says. “While there might be some hesitation of current older adults using technology to receive health and rehab services, the older adult of tomorrow likely is very comfortable using technology. This represents a large opportunity to develop and establish the telehealth/rehabilitation model of care.”

These findings are important because telerehab is becoming much more widely implemented.

“Prior to the outbreak, telehealth/rehabilitation was highly recommended in Canadian stroke professional guidelines, but was underused,” Sakakibara says.

“Now in response to COVID-19, the use of telerehabilitation has been accelerated to the forefront. Once these programs are implemented in practice, it’ll be part of the norm, even when the outbreak is over. It is important that we develop and study telerehabilitation programs to ensure the programs are effective and benefit the patients.”

 

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Rehab groups call for pandemic-fuelled change

An influential group of rehab organisations has issued a set of recommendations to the Health and Social Care Select Committee (HSC) aout managing rehab amid COVID-19.

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While the healthcare system rightly initially focused on saving lives and stopping the spread of the virus, there is an array of patients that remain with unmet needs which The Community Rehab Alliance, a consortium of 22 charities and professional bodies – has submitted a joint response addressing.

Having identified that many COVID-19 survivors are being discharged without any rehabilitation plan in place, the report gives a series of recommendations for services that support rehab across a range of conditions to aid getting the country back on its feet and back to work.

It has been argued that this is a time to learn from the pandemic to shape rehabilitation services for the future, as well as addressing the weaknesses within the arguably under-developed part of the current healthcare system.

Rehabilitation is the process of assessment, treatment and management of a patient’s condition, within which they are supported to reach their maximum potential for physical, cognitive, social and physical participation in society and quality of living. Rehab needs to empower people to recover and build up resilience at their own pace which, for COVID-19 survivors is wide-ranging.

While there are some excellent examples of regional and local responses and pathway development, overall planning and guidance on COVID-19-related rehabilitation appears inconsistent and disjointed. The Rehab alliances recommends a national, strategic approach including integrated care systems carrying out audits, agreement on common rehab needs assessment frameworks and building up multi-disciplinary community rehab teams with the skills and staff required.

By redeploying the workforce – permanent and temporary – back into the community, it is more possible and likely to deliver commitments that will increase step-down rehab capacity.

During the crisis, it hasn’t been only coronavirus patients who have required healthcare. Throughout the pandemic, people are still having falls and fractures, strokes, heart attacks, preparing for cancer treatment or recovering from it, having accidents and illnesses that result in spinal cord and brain injuries and having exacerbations and acute episodes related to long term conditions, including cardiovascular, respiratory, musculoskeletal, rheumatology and neurological.

In all these situations, early, timely and sufficiently intensive rehabilitation will often be critical to people’s long-term recovery and the level of wellbeing and independence people regain or maintain. For older people timely rehabilitation is key to support people to prevent decline, optimise independence, prevent hospital admissions and the need for long-term care. Rehabilitation enables people (including key workers) to return to work and participate in society after lockdown.

During the pandemic, some essential and time-urgent elements of rehabilitation have continued, while supporting shielding and social distancing.

Local managers need consistent advice and time to assess when rehabilitation interventions are essential and on how community rehabilitation can recommence fully. National support and guidance for the provision of telehealth and digital rehabilitation options where appropriate is necessary, with professionals bodies needing to play a critical role in providing guidance on how practice might be adapted from face-to-face rehab from outpatients centres to home, as well as finding alternatives to clinic-based appointments and services.

As services recommence, there should be a positive risk approach, supporting ongoing guidance on social distancing, testing for professionals and carers, PPE at the appropriate level, and prioritisation on the phasing in of aspects of services.

The pandemic is shining a light on the poor state of community rehabilitation provision. While there are many excellent services, access to rehabilitation is a postcode lottery, with services being under- resourced and under-developed for decades. Planning and commissioning is inconsistent, and there is significant variation in standards.

There must be a plan to meet the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak, as well as meeting demand for additional mental health services.

As part of this plan, the Rehab Alliance recommends that there is a strategy to expand both community rehabilitation provision and, where necessary, retain planned additional capacity for step-down (bedded) rehabilitation units.

Through the forthcoming NHS People Plan, deliver an expanded rehabilitation workforce, including allied health professionals with advanced practice skills, support workers and care assistant trained to add capacity, sports and exercise professionals, postural stability instructors, coaches working in the voluntary sector and rehabilitation medicine doctors.

Because COVID-19 is a multi-systemic condition, with significant physical and mental health consequences, it illustrates very well the continued importance of shifting an approach to rehabilitation away from one that is based on neat medical specialisms and condition silos.

The experience of Covid-19 recovery should provide an impetus to adopting a personalised, multi-condition, biopsychosocial approach that can respond to the needs of increasing numbers of people having multiple conditions impacted by multiple factors. This approach needs to support greater inclusion of vulnerable and hard-to-reach groups, who have the worst health outcomes and experience barriers to services. This includes people with learning difficulties, dementia and serious mental illness.

Services need to make reasonable adjustments to make them accessible – for example, adapting communication.

The pandemic has necessitated a shift at scale to online management systems in the community and tele-health. As services get back to normal, it is highly likely, this could be continued to make this a much more prominent option for people in how they access and receive services.

This must be appropriate, evidence based and result in increase choice and access, not in greater marginalization of some groups and increased health inequality.

Learning from the experience of the pandemic should be captured by robust research and shared so that evidence underpins the future shape of rehabilitation. These should include the perceptions of the patients, staff and carers as well as their clinical effectiveness.

So while there is a certain amount of support available, the necessity to address and reform the rehabilitation services available throughout the UK is significant and immediate.

The Rehab Alliance, which includes industry bodies and charities such as Age UK, the Royal College of Psychiatrists and the UK Acquired Brain Injury Forum, is working to see a change across all rehab services offered nationwide to combat the challenges faced as a result of COVID-19 and strengthen those survivors in the best possible way, setting a new standard and practice in services that will better serve residents across the board.

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