91 - Q&A with Dr Groysman Part 1

Epsiode 91 of the Long Covid Podcast is a question & answer session with Dr Groysman, who you will have heard in previous episode talking about the Stellate Ganglion Block.

This is part 1 of this session as it ran quite long - the link to the second half is below (or wherever you get your podcasts!)

If you have more questions for Dr Groysman - or indeed any of my guests - do get in touch.

Dr Groysman episode on Stellate Ganglion Block

Part 2 of this interview

For more information about Long Covid Breathing courses & workshops, please check out LongCovidBreathing.com

(music credit - Brock Hewitt, Rule of Life)

Transcript

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Jackie Baxter  
Hello, and welcome to this episode of the long COVID Podcast. I am delighted to welcome back Dr. Robert Groysman, for this very special question and answer session today. So we have a load of kind of pre-submitted questions, and we're going to work our way through them and do our best to get some answers. 

And if you're interested, then I would definitely recommend going back to Episode 76, where we talk more in depth about the stellate ganglion block. Today I think we're going a bit more broad band. So a very warm welcome back, Dr. Groysman.

Robert Groysman  
Thank you so much, Jackie. Pleasure to be back.

Jackie Baxter  
Yeah, it's lovely to see you again. I was gonna say on this very sunny morning, but it's actually not sunny, and it's no longer morning. So

Robert Groysman  
it's not sunny here either. But it is morning.

Jackie Baxter  
It's morning for you. Yes. So if you are happy, let's just kick off. 

So our first question is on dysautonomia - somebody who's interested to hear a bit more about that. They've tried a Schellong test. I hope I've pronounced that right multiple times for PoTS and hypotension, which has always come back negative, yet orthostatic intolerance is terrible and forces them to spend most of the day horizontal. Are there other ways to kind of prove dysautonomia?

Robert Groysman  
it's possible to do some indirect testing of the autonomic nervous system, you can do heart rate variability test, ideally, using a holter monitor, over 24 hours, at least. You can also do a tilt test, which will tell you if you have orthostasis, if you're not sure. Ortho stasis is basically an effect on heart rate and or blood pressure when you go from a supine or laying down position to a standing position. 

There's other types of tests that look at sweating. And the response to an electrical stimulus is called the Q-star test. There's a way to check with kind of a litmus type paper and see where and how much sweat is developed after a small electrical stimulus. 

But these are all indirect ways to measure the autonomic nervous system, some focus more on sympathetic, some for focus more on parasympathetic. And some just look at the overall autonomic nervous system. Those are basically the main ones to test for it. But you can typically diagnose it with just history and just talking to the patient.

Jackie Baxter  
Sure. And we talked a load about the vagus nerve when we talked previously, and how it can kind of I don't know what the technical term is, but kind of go out of whack. And is the vagus nerve, or can the vagus nerve be actually damaged? Or is it more just that it needs to be put back into balance?

Robert Groysman  
So when we look at the vagus nerve, we know there's dysfunction there. How do we know - based on the symptoms and questionnaires and surveys that have been done. There's also been exams both with MRI and ultrasound showing that the vagus nerve is thickened, not the entire length of it, but certain portions are thickened. Thickened nerves don't work, as well as normal anatomical nerves. So So there's definitely some evidence pointing to at the very least, the vagus nerve dysfunction. 

So out of all the nerves in the body the vagus nerve is kind of special. If you notice it has kind of its own name, compared to everything else which are labeled after what they do or where they're located. The vagus nerve is called the Wanderer. Vagus means wonder in Latin. And it controls many, many things. And it doesn't just receive information from the body, it also outputs and controls different things. It is connected to almost every organ. And one of its major duties is the gastrointestinal system. So everything from swallowing, to a part of taste, it covers part of the back of the throat, and back of the tongue to swallowing reflex. The actual swallowing action is controlled by the vagus nerve. That's why some people have issues with the voice or swallowing problems or even a sore throat. 

It controls peristalsis which means that the food after you swallow, you sort of lose control of what happens to whatever you swallowed, but the vagus nerve knows what to do it. Kind of Slinkys it down the oesophagus and opens the the sphincter so that it gets into the stomach and so forth. It gets into the small intestine, the large intestine, and then finally gets excreted. A lot of that is controlled by the vagus nerve. There's also some enteric autonomic nervous system nerves there that handles some of the rudimentary stuff, but the vagus controls when it happens, and what. Vagus nerve goes to the heart, it controls heart rate, it lowers the heart rate, it decreases the force of the beats of the of the heart, it goes to the lungs, and controls how wide the bronchioles are. And makes it easier or harder to breathe. It controls mucus, it controls salivation. 

I mean, there's so many things that the vagus nerve contributes to. So that is why when it malfunctions or doesn't work well, it affects so many different parts of the body. One of the indirect things that the vagus does or the parasympathetic does is controlling inflammation. Vagus doesn't work well, you don't heal well. You don't maintain your body well. And you may not sleep well as well, because it helps you relax and reduce anxiety and things like that - it actually communicates with the brain as well. So the short answer is, right now we know it's a dysfunction, not necessarily physical damage. But hopefully with time and treatments, it will repair.

Jackie Baxter  
Yeah, so the next question is about Tinnitus caused by COVID. So someone's wanting to know what you know about it, and sort of the mechanism behind it, because they say that hearing tests and MRI have come back showing no damage, yet they have tinnitus. So we talked about this a little bit last time, I think, but yeah, let's get into this.

Robert Groysman  
Yes. So it is going to be speculative. And there's really no studies right now that I'm aware of looking at the actual mechanism of what causes tinnitus in long COVID or post COVID. However, I suspect it's one of two, or maybe a combination of these two. 

One is is that you know, during long COVID many people develop neuropathies, which is inflammation of a nerve or nerves. And there's no reason that the auditory nerve would be spared, because it involves other cranial nerves, including the trigeminal nerve, including the vagus nerve, we know that. So there's no reason why it wouldn't involve the auditory nerves and some people. And being irritated, instead of feeling pain or numbness or tingling, the way the brain perceives irritation of the auditory nerve could be tinnitus. 

The second is the vagus nerve. We know it's involved in the auditory canal and may be somewhat involved in contributing or causing tinnitus that way, because we also know that by stimulating the vagus nerve, many people have reduced their symptoms of tinnitus. So those are the two main mechanisms that I speculatively think are involved in this. 

Jackie Baxter  
Sure. That sort of makes sense, doesn't it? You know, that if all the other nerves are affected, then why wouldn't that one be? It just manifests itself in a slightly different way. Cool. 

So we have a question next on Spike proteins. So it might be useful actually, if you could just say a little bit about what they are for anybody that doesn't know. But the question is about how they can get rid of Spike proteins, and is there a test to show them?

Robert Groysman  
So the spike protein is on the surface of the COVID 19 virus, the SARS cov-2 virus and that is the main mechanism of how it enters our cells. And that occurs when the spike protein contacts the ACE two receptor on the cell. And the ACE two receptor basically sucks the entire virus in by merging the outer covering of the cell with the virus and then the genetic material of the virus enters the cell, and the spike protein remains in the outside. That's generally the mechanism. 

Vaccines have used segments or fragments of Spike proteins for you to develop immunity against the spike protein to ideally, I mean the whole point I think was to prevent entry of the virus into the cells. I don't know how successful it's been, based on current research, but we know that some people have still circulating spike proteins, many months after the infection or even after vaccination, that's been shown several times. 

And these spike proteins can be thrombogenic, which means that they promote clot formation. That's number one. Number two, they're also considered a toxin. And they can continue creating chronic inflammation in the body. 

There's really no good way to test for the spike protein. You can test for antibodies to it. Some of the viral tests, the antigen tests, I'm not sure if they only test for the spike protein or the entire virus. That may be one way. 

So getting rid of Spike protein, I mean, there's been several methods suggested, I don't know the success of them exactly. But one is intermittent fasting, which can help through the autophagy process. Another one would be something like Nattokinase or streptokinase. Nattokinase has been shown to destroy spike protein, at least in vitro, in a petri dish. Those are kind of the main ones, there are others. But those are the main two that will be considered useful. 

Not everybody with long COVID is going to have circulating spike proteins or spike proteins in the system. And we're not clear why some people still have them. And some people have gotten rid of them - may be an immune function. Because not everybody develops long.COVID. Right.

Jackie Baxter  
Are they something that the body should - and probably will maybe over time - just kind of sort out themselves?

Robert Groysman  
Well, there's been some, I guess, chatter with macrophages or monocytes retaining the spike protein within them. I don't know how much I believe in that. But it's possible that cell is disabled by the spike protein. But it would be better to talk to a molecular biologist, or an immunology major, you know, to get more information about that. But it's important to know that not every single person has circulating or spike proteins in their system.

Jackie Baxter  
Yeah, no, it's interesting, isn't it? So does long COVID - or I suppose it would be the COVID virus rather than the long COVID - does it hibernate in the body similar to the herpes virus?

Robert Groysman  
Some people believe that, but I have not seen any evidence in any studies yet showing that it hibernate or kind of lays low and then comes out of hibernation. Herpes virus family does that. Hepatitis B and C can do that. Those are the main ones. And obviously HIV does that. But so far, there hasn't been definitive proof that the COVID virus does this. 

The fact that you have spike protein still in the system doesn't mean that the virus is actively replicating. These may be remnants post infection. The only proof of virus so far that we found has been a persistent virus. In other words in people who've died from COVID, or some other related mechanism and had COVID. They've had virus in various organs in post mortem autopsies and that kind of stuff.

Jackie Baxter  
We've got a next question on long COVID and medically induced menopause. So this person is talking about symptoms that are not that dissimilar. But if you were to explain the effects and how COVID has exacerbated Peri and menopausal symptoms, this may enable impacted women to position their symptoms, condition and impact. So it's yeah, it's kind of about the crossover between the two and how they can impact each other, I suppose - if you're able to maybe shed any light on that at all.

Robert Groysman  
I don't have really any information on the mechanism. But I can confirm that long COVID, or during long COVID, there's been changes in the menstrual cycle or the periods in the way it manifests compared to before long COVID, before you were infected, number one. Number two, there are some studies pointing to potential infertility. I don't know if it's permanent or not. And the third thing is is premature menopause. Some women have been pushed in to early menopause during long COVID, those are all known. In guys there's been other sexual dysfunction reported. But we don't really know - well I don't really know what the actual mechanism is for this.

Jackie Baxter  
Yeah, it's a bit unknown. In fact, there's a paper just released, I think it's the patient led research Collaborative on menstruation and long COVID. And there's actually another study that's hopefully starting, I think it's Imperial College London, who are looking into doing one as well. So that sounds like there is some stuff starting to happen in that direction. But there's so many areas to explore. 

So, a question on iron deficiency. So this person is saying that their iron deficiency is feeling very similar to some of their long COVID symptoms. And the doctor is saying that it's actually not long COVID anymore as it's been, quote unquote, too long. And they're wondering about the relationship between the two. You know, is it long COVID? Is it anemia? Is it both and and there's a kind of exacerbating the other kind of thing going on there.

Robert Groysman  
So let's talk about ferritin. First, ferritin is a protein that's in your blood. And its primary role is to store excess iron, when your blood needs it to make more hemoglobin. But in long COVID, because it is an inflammatory process, many people have an elevated ferritin level. And it doesn't reflect the iron content, but it can actually even mask iron deficiency, anemia, because ferritin levels look normal. But normally, in iron deficiency, anemia, ferritin levels would be low. So long COVID can mask our iron deficiency. We know that iron tends to be low in long COVID Because it's not absorbed well. And that's because of the gut dysbiosis that happens. And there's increased utilization. 

So between those two, a lot of people do have iron deficiency, anemia, in long COVID. Iron deficiency anemia has certain symptoms. There is no such thing as it's been too long for long COVID. Because we don't really have a timeframe of how long is too long. There's no set time where it says, Well, it's been three years, okay, no more. I mean, it just doesn't work that way. It is as long as it is. 

So most of the symptoms related to anemia would be related to fatigue, and general tiredness, and, you know, issues with that, maybe irritability, but it wouldn't really encompass all of the symptoms of long COVID. I mean, I'm not saying that the anemia can't contribute to some of the symptoms of long COVID. And maybe part of the symptoms is from anemia, in some people, but it certainly won't represent all of long COVID. Not all the breadth of symptoms that exist. This anywhere from 170 to 200 symptoms, depending on which study you look at. Iron deficiency anemia simply doesn't have that many symptoms to represent.

Jackie Baxter  
So it's totally possible that actually, it's a combination of both. 

Robert Groysman  
It's very possible. Yes, in fact, we do see iron deficiency anemia, as I said, many times in people with long COVID, and the iron is low, and the ferritin is low. But if the ferritin is not low, you can't necessarily say it's not iron deficiency anemia, because if they have the chronic inflammation, it can make you believe that ferritin levels are normal. When they're really not. They're elevated because of the inflammation. In fact, there was one study looking at, you know, diagnosing long COVID By looking at ferritin levels. I don't know if that's been repeated yet, but it's out there. 

Jackie Baxter  
Sure. I mean, you do hear again, this is anecdotal, but you know, you do hear of people, you know, taking some sort of iron supplement and it making them feel slightly better. So that would kind of back that up, that maybe there is some kind of iron deficiency, that it's not the whole story, but it might help 

Robert Groysman  
I'm gonna, I'm gonna put this out here as a disclaimer, please don't just go out there and take supplements on your own. Do it in the coordination with a physician, so that you can monitor for side effects and problems. There is also a problem with getting too much iron, or any of the supplements. Certain ones can cause, not just side effects, but kind of more longer term problems. So don't try to take it on yourself even though I know that most of these supplements are available over the counter, try to coordinate these with a physician or healthcare provider you trust.

Jackie Baxter  
Yeah, definitely. Yeah, absolutely. So there's a couple of questions about the low dose Naltrexone. Someone's asking you to talk a little bit about it, but they're also asking what sort of dosages you might suggest.

Robert Groysman  
So, low dose Naltrexone is not new for long COVID. It's been around for many years, it was trialed for chronic fatigue syndrome, and it was trialed for fibromyalgia as it was shown to be helpful. Low dose Naltrexone has a different function than full dose Naltrexone. Normally, Naltrexone is used to reverse the effects of opioids or narcotics. That's its main purpose, and it's prescribed at a commercial dose of 50 milligrams. 

But something happens when you decrease the dose to between one and five milligrams, the most commonly studied those is 4.5 milligrams, and it can be taken once or twice a day. At least, for long COVID one protocol is to start at one milligram and every week, you increase by half a milligram until you reach 4.5. Some protocols just start at 4.5. Once a day. You need a minimum of a month, before you see any effect. Some people need as long as three months. It's a slow process. This is not a one day or over the weekend results. And you know you're done. 

Because it's not available commercially, in those low doses you still prescribed, but you have to go through a compound pharmacy. So it's still a prescription medication. But it has to be ordered through a compound pharmacy that will either put in a liquid for you or in capsules. So the cost should be under $100 for a month. I've heard people telling me, they've seen prices of 9000. That is absolutely ridiculous. Sounds like price gouging. Just so people have an idea of how much it should cost. 

Low dose Naltrexone is helpful for fatigue, for mainly for fatigue. Some people have reported some improvement in brain fog, this is not going to fix the other issues, okay? People need to understand that - it's not going to fix taste or smell. It's not going to fix the anxiety. It's not going to fix the GI issues. It's not going to fix any of the other problems associated with long COVID. It's just you know if you expect that doesn't happen. I don't want people to have false expectations of what it can and can't do.

Jackie Baxter  
Sure. And someone is asking about side effects from low dose naltrexone - is there a better time of day to take it to reduce side effects? They're saying the side effect they had when they tried it was increased fatigue. So is it - I know LDN is supposed to treat fatigue so I was not sure what to do when it caused more fatigue instead,

Robert Groysman  
if it's causing more fatigue, I would take it at night. You know, just use common sense. You know, if you're taking it during the day, and it's causing increased fatigue, take it at night. The major side effect of low dose Naltrexone is potentially reversing opioids, even though it's a low dose, the potential is still there. So if you're taking an opioid for pain, chronic pain, post surgical pain, be aware that if you take them close together, there's a chance that it may reverse some of the effects of the opiod. That's the main one. Yes, there's other side effects, but for the most part LDN is tolerated very well, by the majority of people.

Jackie Baxter  
Sure. And I suppose that goes back into what you were saying a moment ago about it being kind of over a month, or a couple of months. So if it causes you side effects over a couple of days or a week.

Robert Groysman  
Yeah, it's a slow process. We're not sure why it's a slow process, but part of what it may be doing is kind of reversing some of the neurologic changes that long COVID causes in the brain. And that takes time. Some studies show there's an anti inflammatory effect as well.

Jackie Baxter  
Yeah, that's really interesting. So COVID hair loss. I feel like I was hearing loads about this at one point and actually haven't so much more recently. So yeah, the question is, what can you do about it? I suppose - they're suggesting vitamins and supplements, but I don't know if that's useful, or if there's anything else you can think of that would help?

Robert Groysman  
At least initially, it's been shown that the hair loss is direct disruption from the virus. Hair growth is typically interrupted if this chronic inflammation, and remember that hair Growth goes in cycles, and each follicle goes through phases. There's a phase where there's no growth happening, where it's just stopped growing, but it's still active. And there's a phase where it goes into hibernation, basically stops responding to anything for a little while. And all follicles do this to some extent. 

There's been some recommendations with things like vitamin E and selenium, either topically or orally, but those really haven't shown to respond during long COVID. One thing to try, of course, is a vasodilator such as minoxidil, that could be helpful. There's other topicals that that sometimes help. It really depends if we're talking about like a clump of hair, or we're talking about global, the entire scalp being involved. The approach may be a little different. There may be like an autoimmune component to it as well, we don't know yet. But I would try all the normal things we would try for hair loss, including possibly a steroid.

Jackie Baxter  
And that's really interesting, I hadn't realized that inflammation could actually kind of impact on hair loss or hair growth. So that's really interesting.

Robert Groysman  
One thing you can try that I prescribe sometimes for hair loss is GHK copper, it comes in, in a gel or foam. And it's a great vasodilator in the skin. So it can help as well.

Jackie Baxter  
So someone is asking about sort of increased sensitivity to, I think sort of sounds and sort of stimulations around them. So I think we're talking, you know, sounds, lights, maybe being outdoors or having to interact with others indoors, brain processing is very difficult. They're wondering if a stellate ganglion block might help with this?

Robert Groysman  
I haven't really seen a whole lot of patients with increased sensitivity, I know what you're talking about. Increased hearing, increased smell, increased taste, everything is magnified. All the senses, I don't know if that's necessarily part of long COVID itself. It is a feature of chronic fatigue syndrome. And some also, you know, you have PoTS and you have chronic fatigue syndrome, and some people have MCAS and all these things are intertwined into one big syndrome. 

A lot of people, not a lot of people, but I think this is more of a rare symptom. If you look at this symptom breakdown. I mean, I'm not saying it's not related to long COVID. It obviously is, but I'm not sure if a stellate ganglion block would treat this or not. I just don't have enough of a patient pool yet to know if this is something that's helpful, or not if this is caused by dysautonomia or not.

Jackie Baxter  
Yeah, because my understanding was that it was related to the fight flight response, because when you're getting ready to fight a tiger or run away from a tiger, you're, you know, your pupils get bigger, don't need to take in more light and your hearing becomes more acute. So I was kind of assuming it was related to that. 

Robert Groysman  
It may be, it may be but normally, it's not to an extent that you can notice that much. You know, the truth is, I don't know. I don't know if this is related to dysautonomia or not. It may be related to sympathetic overdrive, it may be caused by something else.

Jackie Baxter  
Just on a completely different note, it's so nice to hear a doctor say that they don't know. So someone here is talking about shortness of breath and palpitations, and they've been suffering for around about 14 months. They've had all the normal cardio and pulmonary tests and had nothing come back, I think that's the implication there. They've tried TENS machine on the ears, but they're worried about the stellate ganglion block and other things. Is there anything else that you would suggest?

Robert Groysman  
So as far as the shortness of breath there's there was a recent study I posted on the Facebook group that kind of looked at organic causes or structural causes and luckily didn't find really any myocarditis or pericarditis, or anything going on in the lungs and all the tests came back normal as this person says. 

So but you still feeling short of breath. You can't deny that you feeling short of breath. So that could be for several different reasons, and I'll go over the palpitations. One is a mismatch of requirement, what your body needs and what your body delivers. That can cause shortness of breath, we call that a VQ mismatch, basically, perfusion versus oxygen availability. If there's a mismatch, and this is controlled by the autonomic nervous system. If there's a mismatch there, and the body is not meeting the demands, or it's delivering too much, and your body doesn't need it, that doesn't respond correctly. Second is is if your heart can't compensate for increased activity. Again, because autonomic nervous system is not working well, you again will have a mismatch- your body needs more and your heart can't deliver. 

There are possible cause could be the diameter of bronchioles - as I said, the vagus nerve controls this, but also, the sympathetic nervous system controls this. And not only did they control the muscles, the smooth muscles that constrict or dilate these bronchioles, but also mucus production. So, if you have your bronchioles too large, which is what the sympathetic nervous system does, in preparation for fight or flight, it's great when you're running. But it's not great when you're normally trying to breathe, all this additional surface volume created, and all the extra volume,  created, in the bronchioles creates more work for you. So it creates the perception of shortness of breath. Because it's much harder - even though it's counterintuitive. 

But if you think about it, if you're moving less air, normally, and you're forced to have to move more air in order to fill all the volume that's created, it will give you the impression of shortness of breath. So those are kind of the main functional ways. You can get shortness of breath perception. 

Again, the sample size is fairly low of people who I've treated with shortness of breath. So I can't really comment if a stellate ganglion block would help or not yet, so it's just too early to know. But I mean, theoretically, it should be helpful because if you're correcting the dysautonomia, it should make sense that the shortness of breath should be corrected if one of those mechanisms is involved. 

As far as palpitations, again, I'm going to point back to the sympathetic overdrive and it makes the heart beat faster and harder. And when you do that, there's more chance it's more irritable, and there's more chance of having extra beats thrown in. It's kind of like a knock in the engine, premature detonation on one of the cylinders. Same thing happens in the heart. 

We see palpitations and extra beats in people who are stressed, we see this in people who have not gotten sleep, we see this in people who have been over caffeinated. So all these things kind of go towards the sympathetic nervous system. That's assuming obviously, you've never had any cardiac arrhythmias or anything else responsible for this, but. And yes, vagus nerve stimulation is actually used to prevent arrhythmias or stop arrhythmias that are not life threatening. You know, they implant them sometimes for that reason,

Jackie Baxter  
That's really interesting. And then there's the shortness of breath can also be - because this is something that happened to me - it can also be an actual breathing pattern disorder. So the breath work can be hugely helpful with that too, which then obviously impacts your palpitations as well, because it will slow your heart rate down. So that's something that was hugely helpful for me personally. 

So next, we've got questions about orthostatic intolerance, which I think we touched on a little bit earlier. But the question is, what are you doing for it?

Robert Groysman  
Orthostatic in intolerance is mainly the symptom of pots or Postural Orthostatic Tachycardia Syndrome. So let's kind of look at what happens in your body and what's supposed to happen and what doesn't happen. So normally, when you're laying down your blood vessels in your legs relax, and let all that blood accumulate in your legs. Even when you stand up, what your body in fact, your carotid sinus which is in your neck, it senses a drop in blood pressure. Why? Because all that blood is in your legs and the heart all of a sudden sees way less blood than it should be. Because it's stuck in your legs. 

So what's supposed to happen is is that the blood vessels in your legs contract and force all that blood back into circulation. Now, in orthostatic intolerance, that doesn't happen, or it's very delayed. So the heart sees less volume, it's getting signals from the carotid sinus saying, the pressure's dropped a lot. And it increases the heart rate and the pump force of the heart. That is part of the PoTS. It's a compensation mechanism because you're not giving me enough blood. So I'm just going to try to pump whatever I have faster and harder. And hopefully, some of it will get in the brain and not make you pass out. That's why some people get dizzy when they stand up really quickly or especially with ortho stasis, and some people pass out. 

So the easy answer is you treat PoTS first. Okay, so this is not technically long COVID, this is more PoTS, and you would treat it with hydration, whether that's oral or intravenous. And if you're going to do intravenous, you're going to use a saline, a normal saline solution, which is more likely to be retained in the bloodstream. Increase in salt intake, wearing compression stockings or something on the lower part of the body. Again, since that mechanism is not working well. 

So  that's we're talking about just managing the symptoms of orthostasis, it doesn't really fix orthostasis because there are issues with the autonomic nervous system, at least for long COVID. In a lot of people, if you correct the dysautonomia, the orthostasis will correct as well. And that could be done with the the vagus nerve stimulation or stellate ganglion block. It should help - you may not completely reverse it, but it should help with the dysautonomia, which is causing the ortho stasis. 

Jackie Baxter  
Cool. Next question is about fatigue, muscle pain and weakness, which are by far this person's worst symptoms. So they say - they keep me from "doing life", which I think a lot of people can understand. They say they've remained about 30% of regular capacity for one and a half years, should they consider the stellate ganglion block? Or is this a spike protein issue that needs to be addressed in different ways? What are your thoughts there?

Robert Groysman  
So if we're talking about chronic fatigue, and and so on, right, and that can cause obviously, muscle aches and pains, and joint aches and pains. Fibromyalgia is part of that as well. It's a myofascial syndrome. Or are we talking about long COVID? And the chronic fatigue related to long COVID?

Jackie Baxter  
I suppose it could be either, 

Robert Groysman  
So part of it could be from chronic inflammation in those areas. And we know that in long COVID plus or minus chronic fatigue, we know that in Long COVID there's inflammatory reactions in the muscle in the joints. In some people, you can see autoimmune type attacks of the joints, not so much the muscle, but usually joints. That's not in everybody though. 

Whether the spike protein is responsible or not, is still unclear. Like I said, not everybody with long COVID has a spike protein circulating, and those that don't still have issues with muscle and joint pain. So it's still really unclear what role it plays, if it continues to cause the chronic inflammation or once the process is started, it just goes on until and until you treat it or fix it. Or there's enough time that passes that your system can automatically adjust. So that's kind of the short answer of it,

Jackie Baxter  
Stellate Ganglion block with would be useful. Or if it was spike protein?

Robert Groysman  
I have found it to be useful, at least in the upper body. For chest pains, for arm pains, for neck pains related to long COVID. Does it work and every single person, No, but it has been helpful.

Jackie Baxter  
Sure. I'm just curious - we've talked about inflammation quite a lot. And you know, we've talked about it as this sort of underlying process of long COVID And I think of lots of other things. What makes inflammation manifests itself in certain ways in certain people. Why does Person X get muscle pains and someone else gets something different? Do we know why certain things in different people?

Robert Groysman  
Fundamentally chronic inflammation is abnormal. Okay, we know that. Acute inflammation is part of the healing process, but chronic inflammation is abnormal. Long COVID causes inflammation, or inflammation causes long COVID - we don't know. But it is fundamentally from the immune system, and abnormality in the immune system is not working properly. So inflammation comes from the immune system, that's linked. 

Why it affects certain parts of the body in one person versus another. We don't know. But long COVID is global, it causes inflammatory changes in most parts of the body. In some people versus others. In others, it's really not clear why there's such a big range of symptoms. And there may be more than just one process involved, not just the inflammation, not just the dysautonomia, there may be something else as well.

Jackie Baxter  
Okay, so this is potentially contentious. But the next question - exercising and post COVID, does it really do harm for everybody? This person is wondering if it could possibly be helpful in some people, but how would you tell which subset of people would it help and which it wouldn't?

Robert Groysman  
Okay. I think it would be helpful in all people, and I'm gonna clarify what I mean. Yes, you're going to have to pace yourself. That means you can only be able to do certain amount of thing, don't push yourself too hard to your breaking point. And then past your breaking point, that's not going to be helpful. Okay. Physical therapy and exercise has been shown to be helpful in PoTS and in long COVID. That is one of the treatment modalities. But yes, you do have to pace yourself. You can't just resume your old exercise routine and assume that you're going to be able to do it, or benefit from it. Because in the long run, if you're down for several days or a week, after trying a difficult routine or, or basically overdoing it, it's going to be more harmful. 

The reason I think it's beneficial in general, is because our bodies are made to move. And if we don't move, if we're always in bed, if we're always in the chair, if we're always sitting on a couch, you get deconditioned. And deconditioning. happens very quickly can happen in as little as a week, muscles start to atrophy and your heart and lungs don't work as well. So you actually harming yourself by not moving, so to speak. So I think it's beneficial for everybody, just in moderation and do what you can and increase as time goes on. As your body can tolerate. But yes, you can build up a tolerance and actually get better each week or each month. As long as you don't overdo it.

Jackie Baxter  
Yeah, I think that's the key, isn't it, it's within what you can do without pushing yourself too far. For me, I've always been a very active person. So my first kind of idea was to just push through and to exercise myself through it. And it didn't go very well. And I think a lot of people have discovered this the hard way. So for me, it was almost redefining what I meant by exercise. So rather than exercise, it was actually right, well, it's maybe better to sometimes call it movement.

Robert Groysman  
Look, you don't have to make yourself feel bad or guilty, though, if it means getting up from a chair and walking to another room. And that's all you can do - fine, then do that. It's not a matter of well, I couldn't do this and this, you know, I'm a terrible person. And, you know, I should be able to do more, or you have to get yourself out of that kind of mentality. You do what you can do. And you build on that and you increase it by little bit each day, or once a week or whatever you can tolerate. 

And it could be really, really, really small changes. You know, taking one or two extra steps may be enough to build up over time. Your tolerance for exercise, and yeah, exercise intolerance and post exertional malaise. Yeah, that's really part of long COVID. But you can beat it. If you just take it slow. And do exercise. Don't just ignore it.

Jackie Baxter  
Yeah. So we're not telling everyone to get up and go running tomorrow. 

Robert Groysman  
No, no, no, 

Jackie Baxter  
it's very much listen to your body and do what you can do.

Robert Groysman  
Exactly do what you can do and do a little bit more each day. And if you can't do a little bit more each da, do a little bit more each week. 

Jackie Baxter  
Yeah, absolutely. Because we know all about the fluctuating kind of symptoms of long COVID. So actually, sometimes you might not be able to do what you did yesterday.

Robert Groysman  
And again, this is going to go back to the disclaimer of you know, if you were able to exercise before long COVID, obviously if you have cardiac issues of pulmonary and if you have COPD or angina because of other problems with your heart or lungs, you know, you're not going to expect to do as much during long COVID. So, if your doctor or cardiologist told you to be careful or, you have to follow those guidelines as well

Jackie Baxter  
well thanks so much Dr Groysman - this episode is running a little long so I'm going to split it here and you can tune in really soon for the second half of this episode. So thanks so much

Transcribed by https://otter.ai