92 - Q&A with Dr Groysman Part 2

Epsiode 92 of the Long Covid Podcast is the second half of my question & answer session with Dr Groysman - the link to the first half is below, if you've not already heard it.

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 1 of this interview

For more information about Long Covid Breathing, their courses, workshops & other shorter sessions, please check out this link

(music - Brock Hewitt, Rule of Life)

Transcript

Jackie Baxter  
Hello, and welcome to this episode of the long COVID Podcast. I am delighted to welcome back Dr. Robert Groysman, who - you will have heard the first half of this episode, hopefully. So without further ado, we are going to just crack straight on with the second half of our q&a session with Dr. Groysman. 

So someone asking about micro clots? - are they just another piece of a big puzzle? And how can we tackle this?

Robert Groysman  
So micro clots were found mainly by one lab, using kind of an inexpensive technique by taking the blood and separating out the plasma, creating what's called platelet poor plasma, and then adding in a fluorescent dye and seeing under a microscope, if any clots form. Now, I don't know for sure yet if all these labs have taken up this, anybody can pretty much do this in any doctor's office with your microscope and this fluorescent dye, and a centrifuge. 

But before we hang our hat on this test, I think needs to be validated. I mean, does it really represent clot formation inside the body? Or not? I don't have an answer to that. I know that long COVID can make you thrombogenic as can COVID. But those are big clots, they can cause a heart attack or stroke or a pulmonary clot in one of the great vessels in your lungs, or kidneys or something like that. But that's not what we're talking about here. 

So are micro clots even significant? Let's say they exist. Let's say it's real and they exist. Have they been proven to be significant? Are they impeding blood flow? Has that been proven? It has not. Nobody yet has shown that it's even clinically relevant or significant. So before you start administering anticoagulants, which are not benign, because if you have a aneurysm, if you have a break somewhere in your body, in your blood vessel, you can kill yourself. This is not just me hypothesizing, this has been shown that they're not completely benign, okay. 

So you have to, you know, anything anytime you do a treatment in medicine, anytime you do any action, you have to look at benefits versus risk. And I don't know if, at least right now, if the benefits outweigh the risks in every single person. So I would just be very careful with anticoagulants, some people are placed on three different ones at the same time. And you can get into a bleeding episode, it could be from your gut, it could be from, like I said, from an aneurysm or an AV fistula or something else in your body that you don't even know you have. And you can bleed out because you're not clotting anymore. 

Now, the anticoagulants I'm talking about are the real major ones, available from the pharmaceutical companies, not things like Nattokinase or streptokinase. Those also cause some anticoagulation, but I don't think it's on the same level as these other ones, and the risk is much lower of a bleed. But still, you know, what exactly are you treating is my question. And is it clinically relevant? If it is there, if the micro clots are there - I know everybody's talking about these micro clots. I've seen the studies. I'm not convinced yet that A. they actually exist and B. if there's even any clinical relevance to these micro clots, you know, are they actually impeding blood flow somewhere? You know, prove it to me, and, you know, I'm good. But I don't want to do a potentially harmful treatment until I'm sure that it's actually treating something.

Jackie Baxter  
So a question about headache. So yeah, looking for recommendations to retreat or reduce pain from post COVID continuous headaches. This is in a child of 11 years.

Robert Groysman  
So first, I want to make sure that it's actually a headache and not scalp pain or muscle pain around the head. We know that there's some headaches associated with post COVID and Long COVID. So I would first want to find out if there's any prior history of headaches. If for instance, the person has had migraines before as an example. It can make migraines worse or exacerbated. 

So if these are new headaches, I would basically workup for a headache, do a full history and exam. And imaging if needed, depending on the way the symptoms present themselves. And a treatment can be symptomatic, just treating the symptoms, or there may be more involved, again, depending on the cause of the headache. And there's so many, many, many causes of headaches - without knowing more information it's really impossible for me to basically say any more on this, but everything always starts with the history and physical, and then we move from there. Are they taking any medications? Some medications can cause headaches as well.

Jackie Baxter  
Okay, so it's possible it's a side effect from something else. 

Right, can stellate ganglion Block help with PoTS? I think we've covered that one, haven't we?

Robert Groysman  
So yeah, I think we've covered that last time, the majority of patients do feel better, even if they have PoTS, as part of long COVID. Like I said, a small percentage of people, and it's small, but they can destabilize their PoTS and have increased fatigue and or brain fog. For a short period of time, it is temporary, but it can happen in somebody with PoTS and long COVID, post the stellate ganglion block. I've seen that in a very small percentage of people, but it's there. 

Jackie Baxter  
Sure, I will pop a link to the previous episode into the show notes for this one, because there is a load more information in there that we talked about previously. 

What is best for low heart rate. So I think we tend to see more high heart rate. But here we're talking about lower heart rate, which I think is a bit more unusual.

Robert Groysman  
It is unusual, it is unusual. So I would again, start with the history and physical and kind of determine why the heart rate is low. Sometimes the medications people are on, like a beta blocker, for instance, or a calcium channel blocker can lower heart rate. And there may be another reason why heart rate is low and low we're talking about under 60. I would see what their prior baseline was, and try to get to the root of the problem. 

Jackie Baxter  
Sure. I think something that I've noticed, I mean, there's there's a lot of people that are now as a result of having long COVID that are tracking their heart rate and their breathing and their HRV. And they're you know, everything. Because they're trying to keep a handle on it, which is probably quite useful in a lot of people. But there's something you just said about - what was their previous baseline? I wouldn't have known what my previous baseline was, because I never measured it before. So I suppose this is something to think about, isn't it? You know, what is low? And what is high? Compared to what you had before? Or you know, it's person to person, isn't it?

Robert Groysman  
Yes, you know, you need to know what you were before - I'm naturally low, I tend to be in the 40s and 50s. Some people are like that, because they're athletes, or they were athletes before, and their heart rate runs below 60 all the time. So it really kind of depends on Yeah, you do need to know baseline and hopefully you would have had that checked at some point during a physical or doing during a routine EKG or something else where it's documented. But yes, you do need to know where your baseline is. So you know if it's abnormal or not, it may be normal for you. And if that's the case, you may not be having much of a sympathetic overdrive. And I would be careful with things like vagus nerve stimulation, because that may theoretically lower your heartbeat even more.

Jackie Baxter  
Okay, yeah, that's interesting. So we've got a question about, I think diet and supplements. So, again, this is probably a huge area. And I have actually interviewed people who are nutritional therapists. So it might be might be worth listening to some of them. But what would your potted couple of minutes worth of advice for diet and sort of any supplementation/vitamins, that sort of thing?

Robert Groysman  
Well, I mean, if we're talking about globally, and we're talking about somebody who does not have issues with parosmia, or anosmia, or anything that would prevent them from eating a balanced diet. The first thing I would consider is there an MCAS component in your long COVID? And if there is, you may want to focus on foods that do not increase your histamine levels, or that can stabilize your mast cells. So without going into specifics, you can look it up what's involved. 

As far as supplemention, if you're taking a well-balanced diet, you may not need anything additional. However, however, in long COVID, I have found, as I said, iron tends to be low. And I think most of these are from either one or the other, or both. Either decreased absorption because of the gut dysbiosis that happens, or, and, from increased utilization - your body needs more because it's undergoing chronic inflammation. 

Vitamin D is another, I find this low in a lot of people with long COVID. I look at most of the B vitamins - B12, and six are often low. Occasionally we find B 12 high. And some of the other B vitamins occasionally are low, even though it's so hard for them to be low if you're basically eating anything, just about, like B1 and B2. But the majority of people are going to have those few things low. And if you find them low, and how do you find them all - you got to test for them, you gotta do a blood test. Don't assume they're low, you got to test. 

And if they are low, and if you're already eating a well balanced diet, that's including most of the nutritional content, then yes, I would supplement. But again, I would still do this in coordination with a physician you trust, or health or care provider you trust. Most of them are not going to cause a problem if you supplement, but iron for instance can. Vitamin D has a potential to but it's unlikely. But still, like I said, it's best to coordinate this with a medical professional you trust.

Jackie Baxter  
Yeah, definitely. Cool. 

So what tests and labs are helpful in determining the root cause of our Long Covid problems? This person is suggesting spike protein, microclots and dysautonomia. But we obviously know that there's many more than just those ones. So what should people be requesting from their health care professionals?

Robert Groysman  
Those tests won't really help - they're not blood tests that can determine those things. I mean, dysautonomia, like I said, is mainly history, physical and performing some of these indirect tests including heart rate variability, teilt tests, things like that. It's really beyond the scope of what I can answer. There's a lot of bloodwork you want to look at. But in general, you're going to look at a CBC with differential, you're going to look at the metabolic profile. And when I say differential, it's going to break down the cells into what cells are in the sample, both white blood cells and red cells and you're going to want to look at some of the inflammatory markers, such as CRP, there's some interleukins you can look at. 

There's nothing so far that's going to be diagnostic for long COVID. It's really mainly a clinical diagnosis based on symptoms you know, you can go into a very detailed bloodwork and looking at all the interleukins and cytokines. I'm not so sure how helpful it is, but some people may glean some benefit from knowing that one of their interleukins is high versus another. I don't know how helpful it is though in the course of treatment. You can look at clotting factors for instance, you could do it indirectly or you can measure these proteins specifically - like I said, depends on how involved you want. 

But remember these are not cheap tests and insurance may not want to cover some of these or all of these, and you can actually get 1000s of dollars in lab bills from trying to get these and I was always taught, you know if we go back to medical school, you know, medical school 101 is don't order a test unless it's going to alter your treatment course. So is it just for the sake of knowing, or is it actually going to change what you do? So depending on who you go, they may have different beliefs but that's just how I feel about it. Don't order it unless you expect or suspect something and you think is going to alter if you're going to do A or B. If you're gonna do C regardless of the test results, then why you ordering the test? It doesn't really help.

Jackie Baxter  
That seems to make sense. Yeah. 

So what treatments are most effective for those with severe neurological issues from COVID, such as myoclonic jerks and speech difficulties?

Robert Groysman  
So we know that these are neurologic, the person asking this question knows it's neurologic. There is no real "best treatment" yet for something like this. Some people do improve after stellate ganglion block. But again, the amount of people that I've treated with these symptoms is very, very low. So it's really hard to make a general recommendation. 

It's inflammation of the nerve pathways, inflammation in the brain, or different areas of the brain. Again, we don't know why some people develop this versus other symptoms. But we do know that neuropsychiatric symptoms are the main part of long COVID, even though involves every single system,. No system is immune from the effects of long COVID. So there is no really no best, or even the definitive treatment for something like this yet. 

Jackie Baxter  
So if inflammation is the cause, then tackling the inflammation might be a route to go?

Robert Groysman  
Yeah, and I mean, some doctors treat these with nerve stabilizing agents such as Gabapentin or Lyrica or Cymbalta. Some people think that they're toxins and won't take them. I'm just saying what I've seen.

Jackie Baxter  
So we've got another question about healing the gut. We touched on this a little bit earlier. This is someone saying "long COVID gave me gut issues." So what would be your advice there - anything different to what we said earlier?

Robert Groysman  
so long COVID causes gut issues in just about every person with long COVID. Whether you have symptoms of gut issues or not, is not really relevant to this. Even if you don't have abdominal pain, diarrhea or bloating or issues with your gut, you could still have gut issues from long COVID. 

And the issues are several fold. One is is that your microbiology or the microtome, of microbiome of the of the gut is changed. Some there may be some pathological bacteria virus or fungus or yeast in there. And one way to treat that is with a good probiotic room temperature stable, don't get anything that requires refrigeration. If you have MCAS or histamine sensitivity, you would need to look up which bacteria not only exacerbate that, but some of them don't exacerbate it, but don't exactly stabilize mast cells. Some do. There's a group of probiotics you can get, specifically if you have MCAS for histamine sensitivity. And I recommend you do that because your symptoms will get worse if you take a regular old probiotic. 

Second is stabilizing the blood gut barrier, which is very similar to the blood brain barrier, which exists in our brain. And it's basically to prevent pathogens, toxins, and basically these two from translocating - moving from the gut into the bloodstream. And if you think about it, you know, food and drink, and whatever you take in is not sterile. Even if it's been cooked, or prepared, there's going to be some bacteria, viral and yeast or fungal matter on it. Even if it was wrapped up nice and tight, and everything it's not a sterile product. 

So our gut is meant to handle these kinds of things. That's why we have immune cells, it's one of the most developed immune systems in our gut, from a lot of other parts of our body. So trying to repair that, and there's a few peptides suggested for that. One of them is BCP 157. KPV is another - there's several others, that can be helpful. But some people will do just fine with the probiotic and will repair just from time and fixing the the irregularityin the microbiome. 

So those are two things and the rest will follow. So things like malabsorption that happens because you have these issues going on, should correct itself over time, once the gut repairs.

Jackie Baxter  
Sure. 

Do you have any insight into how the adrenals can be affected by long COVID?

Robert Groysman  
Yes. So what do the adrenals do? They excrete or secrete epinephrine and norepinephrine as a response to an increase signal from the sympathetic nervous system. And the reason that happens is it's basically an effector because the sympathetic nervous system is not connected to every organ and body area like the parasympathetic is. So it uses a chemical way to activate everything. Epinephrine, as you know, makes your heart race and your blood vessels constrict. And your bronchioles to dilate. So that's kind of one of the process. 

And when people talk about adrenal dumps, that's because your sympathetic nervous system is activated a lot of time. And the adrenal is just doing what the sympathetic nervous system is telling it to do. Your body also secretes or excretes, cortisol to try to deal with all that stress. So with cortisol in your system, your sugar will go up as well. Because that's part of the fight or flight response. So it's trying to calm it down. It's always a give and take with the autonomic nervous system.

Jackie Baxter  
Right? That's fascinating, isn't it? How it's also connected? Like everything is connected to the same thing, isn't it? 

Robert Groysman  
Yes. 

Jackie Baxter  
So got a question about skin on the lower legs. "What could cause the skin on my lower legs do feel stiff? If I sneeze, I feel it in my lower legs"

Robert Groysman  
I'm not exactly sure what the person means by stiffness. So some people have changes in their skin. Part of it could be due to the MCAS, part of it could be due just to the connective tissue changes during long COVID. I'm not really sure how to answer that. Except that way.

Jackie Baxter  
They say "I assume it's a nerve issue"

Robert Groysman  
It's not - I mean, stiffness is not typically a nerve issue. It's more of a muscle, tendon or ligament issue.

Jackie Baxter  
Well, that narrows it down a little bit. 

Okay, so we've got another question about the stellate ganglion block - "I understand the stellate ganglion block is a reboot to the sympathetic nervous system. If one has the SGB, but still has spike proteins, will the SGB be effective? Should we take steps to repair both areas?" I know we touched on this earlier

Robert Groysman  
Right? Well, the whole spike protein thing is still somewhat speculative, whether some people have it or not. So I don't know if this is definitive test. I mean, I could be wrong. And there is but I haven't I haven't seen it yet. That's not something I typically deal with. But one really doesn't have anything to do with the other. If it is the spike protein continuing to cause the chronic inflammation, then yes, you'd want to stop that process if possible. You know, things like nattokinase can help. And I just don't know what percentage of people actually have circulating spike proteins compared to not. I don't know if there's been any studies done looking at demonstrating it - it's very speculative, as I said, it's not definitive. 

So it's a hypothesis, not even a theory. It's a hypothesis still out there. But because it's not, it's not really known. I don't know. I mean, if you want to do a round of nattokinase, or basically a treatment that is known to help with the proteins, that's fine. But I don't think it's really related to the stellate ganglion block, except that you may have a resurgence or recurrence if there's still something in your system that's causing the inflammatory reaction.

Jackie Baxter  
So I think the next question is about specifically coming to you as a patient. Why do you have to see a specialist before getting treatment from you? Is it because you need a diagnosis first?

Robert Groysman  
it don't necessarily need someone to see a specialist before they come see me. I confirm that this was either COVID related or vaccine related, in some sense. But you don't necessarily have to see a specialist. But if you're curious if it could be something else besides long covid, I would, but it's not absolutely necessary.

Jackie Baxter  
Right. 

Why is there typically a delay in symptoms after infection? I think this might be different for different people. So maybe the question should be, why could there be a delay in symptoms after infection?

Robert Groysman  
Because it's chronic inflammation, and chronic inflammation takes time to form. It may start with an acute inflammatory reaction. And in some people, they develop the cytokine storm, and because the cytokines are very pro inflammatory, at least some of them are, it may said the chronic inflammation process in motion, and that takes time. You don't get chronic inflammation one day after infection, you just don't. By definition, chronic inflammation in general takes, you know, a few months to develop.

Jackie Baxter  
Right. So that could explain why there seem to be quite a lot of people, certainly, who had their initial infection, and then maybe seem to be kind of okay for a couple of months and then boom. Then it hits.

Robert Groysman  
On the surface, it looks fine. But if you dig deeper, there's there's things happening under the surface. And if you get tested, you'll see those inflammation markers up. 

Jackie Baxter  
That's interesting. That's what happened to me. 

Right. Why are some people affected and not others?

Robert Groysman  
We don't have an answer for that yet. We don't know why long COVID happens in a fraction of the population and not the others. There's been a lot of speculation and talk about people who are more at risk, such as women compared to men, for instance, such as the age of the person, young people tend to be less likely to develop it than older people. People with autoimmune conditions, such as rheumatoid arthritis, lupus, Crohn's disease, ulcerative colitis, and there's several others that tend to be more at risk. I mean, the increase in risk is small, but it's there. 

And certain viral infections, or bacterial infections can put you at risk, such as Lyme disease, prior Lyme disease, Epstein Barr Virus, but the thing about Epstein Barr is - who hasn't had mononucleosis as a kid or as a teenager? So I don't know. I mean, I think the majority of thr population has it or has been infected with it at some point. And I wouldn't use that as one of the risk factors, because just almost everybody has it. So that's all we have right now. We don't know beyond that, why some people develop it and others don't. There may be some genetic predisposition to it as well, which we don't know yet. It's just speculation.

Jackie Baxter  
So we've got another question about severe brain fog. I think we sort of touched on that earlier, didn't we?

Robert Groysman  
We did - there's a lot of different potential causes for brain fog. You know, one is the chronic inflammation that occurs in, or could occur, in the brain. Another - there is a vascular change or blood flow change that's happening due to the sympathetic overdrive in the brain. Third, could be from lack of sleep, or lack of good sleep, deep sleep that people are getting. Fourth could be the medications that some people are on. 

So there, there's a lot of potential causes for the brain fog. And you can say the same thing for the fatigue as well. And the last one I'm going to mention is the gut. You know, if we're talking about a dysbiosis, or having pathogens in there that could be sending toxins directly to the brain. And we already know there is a gut brain axis, and that's actually been shown to cause chronic fatigue  - that's part of one of the causes of chronic fatigue.

Jackie Baxter  
Yeah, so there's definitely some some ideas to follow up at least there. 

There's a wee question about - we've covered tinnitus already. But how does COVID Cause Parosmia and Dysgeusia? 

Robert Groysman  
So most people who develop issues with smell initially develop anosmia. No taste or smell, either during the COVID infection or immediately after. And some people handle it well, some people don't. And what happens within anywhere from a couple of weeks to a couple of months, is that if the smell will come back, or the smell will turn into parosmia and dysgeusia. 

So the way I look at this is kind of a brownout, a reset. Your body tries to fix it, but it doesn't quite get there. And you need the reset of the system in order for it to work. This may be again regional blood flow changes that happen from the sympathetic overdrive for people who have it. It may be the autonomic contribution to the area. I mean, obviously, we know the vagus at least is involved partly with taste, maybe not smell, but taste. 

And the exact mechanism is unknown. We do know in the beginning, in the beginning of the infection, the issue is direct invasion into the epithelium and the support cells. So these nerves don't just sit there naked and exposed. They're surrounded by support cells and some epithelium to protect them. And we know that COVID can infect those cells. We also know that COVID can affect nerve tissue. But I think the majority of the issue is, is that there's some damage to the epithelial cells and the support cells in the nose, in the olfactory bulb area. And while that may repair, it needs kind of a reboot, to get it going again. 

And the the body's attempt to reboot, unfortunately, sometimes ends up with the parosmia and dysgeusia, and you need to have an outside source rebooted to get it to working normal again. If this was damage, and you did a static ganglion block, and you get a result within 30 seconds after the block - damage can't repair that fast. It just can't. Chronic inflammation can't be reversed that quickly. So whether it's one of those mechanisms I mentioned, or by some unknown mechanism, that's still yet to be discovered. It's a functional problem. It's not a physical structural problem.

Jackie Baxter  
And one final question, how do we get others - particularly doctors who aren't compassionate like yourself - to take us seriously? So I think this is a sort of counter to some of the gaslighting that some people might have been experiencing.

Robert Groysman  
I mean, the best way is just to open yourself up to learning new things and looking at some of the studies and what's out there. And recognizing and realizing that long COVID is not in people's heads. It's an actual medical problem. And it is associated with chronic fatigue, it's associated with PoTS, and it's associated with MCAS. And it's a multi systemic condition that requires a multidisciplinary approach to treat or, you know, it's not just one physician - but the bottom line is is believing your patient. And listening, is really the only way people can get beyond this. 

Like I like I mentioned earlier, chronic fatigue used to be in this category, nobody believed it was real. And Fibromyalgia used to be in this category, and people get sent to psychiatrists all the time, saying it's all in their heads. Nothing was coming back positive, and any bloodwork and any MRI or imaging, and any of the tests done, everything was coming back normal, so it must be in your head. But this is not in people's heads. Nobody wants to have this. I mean, nobody's seeking medical attention, just for the sake of talking to a doctor. I mean, you ain't that special, okay? 

So they're there for a reason they're suffering. And, you know, just listen, listen to your patients. Don't roll your eyes, don't dismiss them, don't cut them off. Just just listen and acknowledge and accept their symptoms is real. Even if the tests come back as normal. Even if the imaging comes back as normal. It's there. It's not - we don't have a definitive test yet. But that doesn't mean that the condition doesn't exist. And that's really it. I mean, you just remember why you went to med school, you know, remember why you're doing this? And hopefully, it's for the right reasons. That's really all I can I can impart. I mean, I think most doctors are good people and their heart's in the right place. It's just very easy to get, you know, jaded when everything comes back normal. And you have to take that leap of faith.

Jackie Baxter  
And as patients, if we feel like we're not being listened to by our doctors, what would you recommend a patient doing in that situation?

Robert Groysman  
Well, I would still, I would still attempt to, to talk. And if the doctor is completely being dismissive, I recommend finding somebody else. That's all there is to it. I mean, you know, if the person is obviously not interested in treating long COVID, they're not the right person for you. Or they're not able to treat long COVID. You know, they just, they don't understand what it is, they don't want to learn anything about it, and they don't want to treat it and that's fine. You know, that's why we have specialists and, you know, find somebody else. There are people out there who are interested in helping and do help. So it's just a matter of finding them.

Jackie Baxter  
Brilliant. Well, I think we've managed to get through our list. So thank you so much for joining me today. We've got tons and tons of answers there. If you've been listening, and you've got more questions, either for Dr. Groysman, or for anyone else, please do get in touch. And if we get enough questions, we might do another follow up. 

Robert Groysman  
Sure. 

Jackie Baxter  
I'll make sure a link to that Facebook group goes into the show notes as well. So if anybody's looking for that. Well, fantastic. Thank you so much - it's been fun

Robert Groysman  
It's been a pleasure Jackie

Transcribed by https://otter.ai