Robert Groysman, MD

12/28/2025

Important clarification about POTS, dysautonomia, COVID, and COVID vaccines

This topic gets oversimplified online, so nuance matters.

Yes, COVID and COVID vaccines can cause dysautonomia, including POTS, in some people.
This is real and well documented.

What they do not do is create a genetic or lifelong autonomic disorder out of nothing.

There are two distinct scenarios that get incorrectly lumped together:

1) Unmasking a pre-existing vulnerability
Some people already have underlying autonomic fragility due to genetics, connective tissue laxity, autoimmune tendency, or prior illness. COVID or vaccination stress can push that system past its compensation point, making symptoms obvious for the first time.

2) Triggering a secondary dysautonomia
Others develop a new-onset, post-infectious or post-immune dysautonomia after COVID or vaccination. This is a secondary form, driven by inflammation, immune activation, autonomic nerve irritation, vascular dysfunction, or deconditioning.

These are not the same as classic POTS that begins in adolescence and persists lifelong.

Why this distinction matters:

If you assume all POTS after COVID or vaccination is permanent or genetic, you risk:
• Missing treatable mechanisms
• Delaying recovery-focused care
• Telling patients their condition cannot improve when it often can

Many post-COVID and post-vaccine dysautonomia cases improve significantly or resolve with proper identification and treatment of the underlying drivers.

Triggering ≠ genetic causation.
Unmasking ≠ lifelong disease.

Precision matters in diagnosis, prognosis, and treatment.

12/28/2025

Important clarification about EDS, hEDS, COVID, and Long COVID, and COVID vaccines

There is a lot of confusion online about this, so let’s be very clear:

Neither COVID, COVID vaccines, nor Long COVID causes EDS or hEDS.

Ehlers-Danlos syndromes (EDS), including hypermobile EDS (hEDS), are genetic connective tissue disorders. You are born with them. A virus does not create a genetic condition. A vaccine cannot either.

So why do people think COVID or Long COVID “caused” EDS or hEDS?

Because COVID can unmask or worsen symptoms of a condition that was already there.

Here is what actually happens:

• Someone has mild or compensated hypermobility their whole life
• They function well and may not meet diagnostic criteria
• COVID triggers inflammation, autonomic dysfunction, MCAS, mitochondrial stress, or deconditioning
• Symptoms worsen and suddenly become obvious
• The underlying genetic condition is finally recognized

That is unmasking, not causing.

The same applies to many conditions commonly confused with Long COVID:
• hEDS
• Dysautonomia
• MCAS
• Migraine disorders
• Autoimmune tendencies

Long COVID can:
• Push a borderline condition into symptomatic territory
• Worsen pain, fatigue, dizziness, GI symptoms, and instability
• Create overlapping symptoms that look similar

But it does not:
• Create new genetic mutations
• Turn someone into an EDS patient
• Cause hEDS to suddenly exist

Why this distinction matters:

If you believe Long COVID “is” EDS, you risk:
• Missing treatable post-viral mechanisms
• Being told symptoms are permanent when they may not be
• Getting inappropriate or incomplete treatment

You can have:
• Pre-existing hEDS worsened by COVID
• Long COVID without hEDS
• Long COVID layered on top of hEDS

These are not the same, and they should not be managed the same way.

Precision matters. Labels matter. And so does understanding what COVID can and cannot do.

If symptoms started after COVID, that does not automatically mean a genetic disorder suddenly appeared.

12/28/2025

Why I prefer the NASA Lean Test over the tilt table test

This often surprises people, but in many cases I find the NASA Lean Test more useful than a tilt table test.

Here is why.

1. It reflects real life physiology

The NASA Lean Test is an active stand test.
The patient stands upright, bearing their own weight, using their own muscles, just like real life.

A tilt table is passive.
You are strapped in and tilted, which removes muscle activation and changes normal autonomic responses.

Dysautonomia symptoms usually happen in daily life, not while strapped to a table.

2. It often provokes symptoms better

Many patients feel worse during a NASA Lean Test than during a tilt test.

Why?
• Muscle engagement
• True venous pooling
• Normal gravitational stress
• No artificial support

If symptoms are going to show up, they are more likely to appear during an active stand.

3. It is easier to reproduce and repeat

The NASA Lean Test can be:
• Done in clinic
• Repeated at different times of day
• Repeated during symptom flares
• Done at home with guidance

Dysautonomia fluctuates.
A single one time tilt test can easily miss it.

4. It avoids false reassurance

A normal tilt test often leads patients to be told:
“You do not have dysautonomia.”

That conclusion is incorrect.

A NASA Lean Test helps identify orthostatic intolerance patterns without pretending to diagnose the entire autonomic nervous system.

It keeps expectations realistic and avoids overinterpreting one narrow test.

⸻

5. It is a better screening tool

The NASA Lean Test is not perfect, but it is:
• Practical
• Physiologic
• Reproducible
• Low risk
• Inexpensive

It is an excellent first step before more specialized autonomic testing when needed.

Tilt table testing has a role, mainly for confirming specific orthostatic diagnoses.

But for everyday clinical practice and real world symptoms, the NASA Lean Test often gives more useful information about how the body actually responds to standing.

That is why I use it so often.

12/28/2025

Why a tilt table test does NOT diagnose dysautonomia

This comes up constantly, so let’s clarify it clearly.

A tilt table test does not diagnose dysautonomia.
It only evaluates orthostatic cardiovascular responses.

What a tilt table test actually measures

A tilt test looks at just two things when you go from lying down to upright:
• Heart rate
• Blood pressure

Based on those numbers, it can identify:
• POTS
• Orthostatic hypotension
• Vasovagal syncope

That is the entire scope of the test.

What dysautonomia really is:

Dysautonomia means global autonomic nervous system dysfunction.

The autonomic nervous system controls far more than standing heart rate and blood pressure, including:
• Vagal tone and recovery
• Blood vessel regulation outside of standing
• Temperature control and sweating
• Digestion and gut motility
• Bladder function
• Stress and exertional responses

A condition that affects multiple autonomic systems cannot be diagnosed by a test that only looks at standing physiology.

Why tilt tests miss dysautonomia
• Many people with dysautonomia are not orthostatic
• Some patients compensate during the test and keep HR and BP in the normal range
• Autonomic dysfunction fluctuates day to day and hour to hour
• The test evaluates one reflex pathway, not the entire autonomic network

A normal tilt test only means this:
Your heart rate and blood pressure were maintained during that specific test.

It does not mean the autonomic nervous system is normal.

The key takeaway

Tilt table testing diagnoses orthostatic conditions, especially POTS.
It does not diagnose dysautonomia.

This misunderstanding is one of the main reasons patients are told “everything is normal” when the wrong test was used to answer the wrong question.

12/28/2025

Why oxidative therapies often make MCAS worse

This is an important concept that gets overlooked.

Some treatments are described as “oxidative” or “pro-oxidant,” with the idea that stressing the immune system will force healing. In people with MCAS, this frequently backfires.

Here is why.

What SOD3 is and why it matters
SOD3 stands for extracellular superoxide dismutase.

It is one of the body’s most important antioxidant enzymes, but unlike most antioxidants, it works OUTSIDE the cell, not inside it.

SOD3 sits on blood vessels and connective tissue, exactly where mast cells live and where immune signaling occurs. Its job is to neutralize superoxide, a highly reactive oxygen radical generated during inflammation and immune activation.

You cannot replace SOD3 with a supplement or IV. It is a tissue-bound enzyme. If it is damaged, depleted, or overwhelmed, oxidative stress builds up outside cells.

MCAS and oxidative stress amplify each other.

Activated mast cells release histamine, tryptase, cytokines, and reactive oxygen species.
Oxidative stress itself lowers the activation threshold of mast cells.

When SOD3 cannot keep up:
Extracellular oxidative stress increases
Mast cells become easier to trigger
More mediators are released
Symptoms escalate

This creates a self-reinforcing loop.

What oxidative therapies do in MCAS
Oxidative therapies intentionally increase reactive oxygen species.

If extracellular antioxidant buffering is already impaired, this leads to:
More oxidative stress around mast cells
More endothelial irritation and permeability
More mast cell activation
More histamine and inflammatory mediator release

Clinically, this often shows up as flushing, anxiety, tachycardia, brain fog, GI symptoms, or post-treatment flares.

These therapies assume a normal extracellular antioxidant defense system.
MCAS patients often do not have that reserve.

Adding oxidative stress to an already reactive immune environment worsens instability rather than improving it.

MCAS is not just a histamine problem.
It is also an extracellular oxidative stress problem.

If a therapy increases oxidative load and the body cannot buffer it, mast cells become more reactive, not calmer.

Stabilize mast cells.
Reduce oxidative stress.
Protect the endothelium.

Oxidative Stress is not therapy for a hypersensitive immune system.

12/28/2025

12/27/2025

Digestive issues combined with heart rate problems. Inflammation that won't resolve no matter what you try.

But here's what connects these symptoms: Your vagus nerve is impaired.

The vagus nerve is your body's superhighway—connecting brain to heart, lungs, digestive system, immune system. It controls heart rate variability, digestive function, inflammatory regulation, even mood. It's 75% of your parasympathetic nervous system, your "rest and digest" mode.

Think of it like the main fiber optic cable connecting a city's neighborhoods. When that cable works, all neighborhoods communicate smoothly. When it's damaged, every neighborhood experiences problems, different symptoms, same root cause.

Long COVID damages vagus nerve function through inflammation, viral injury, and autonomic dysfunction. The result? Multiple seemingly unrelated symptoms that are actually connected:

Digestive: Slow motility, constipation, bloating, reflux (vagus controls gut movement)
Cardiac: Heart rate variability loss, palpitations, inappropriate tachycardia (vagus regulates heart rate)
Inflammatory: Chronic inflammation that won't resolve (vagus activates anti-inflammatory pathways)
Mood: Anxiety, depression (vagus communicates gut-brain axis)
Immune: Excessive immune activation (vagus modulates immune response)

All connected through one nerve pathway.

Testing vagus function: Heart rate variability is the gold standard. Low HRV indicates vagus impairment.

Improving vagus function: Gargling forcefully, singing loudly, cold water face immersion, humming, specific breathing exercises (long exhales). Stellate ganglion blocks significantly improve vagal tone for many Long COVID patients.

Your scattered symptoms might have a single common pathway. The vagus nerve connects them, and therapies that restore vagal function improve them all.

12/27/2025

True healing begins in the gut.

Volume 4 of The Complete Long COVID Handbook explores how COVID-19 disrupts your microbiome, the trillions of bacteria that protect your gut barrier, produce vital nutrients, and regulate inflammation.

When butyrate-producing bacteria disappear and biofilms form, symptoms like bloating, food sensitivities, SIBO, and brain fog emerge. This isn't just about killing bad bacteria. It's about understanding LPS spillage, repairing your gut lining, and restoring balance.

Volume 4 includes protocols for addressing biofilms in your nose and throat, often-overlooked sources of ongoing problems, and introduces Epipharyngeal Abrasive Therapy (EAT) as a gentle reset for your upper airway.

Learn more: https://www.longcovidfamily.com/shop/

12/27/2025

Hi guys, here is your chance to have a say in what goes into ALL long COVID symptoms mapped to the primary 6 mechanisms (yes all 234, this is the TOC, additional symptoms are listed in the index in the back). Feel free to make suggestions on anything you don't see but would like. Please avoid listing the 6 primary mechanisms as a symptom. Thanks.

Abdominal Bloating
Abdominal Burning
Abdominal Cramps
Abdominal Pain
Adrenal Exhaustion
Adrenaline Surges
Air Hunger
Alcohol Intolerance
Amenorrhea / Oligomenorrhea
Angioedema
Anemia
Anhedonia (Inability to Feel Pleasure)
Anhidrosis (Inability to Sweat)
Anxiety
Aphasia / Language Problems
Arrhythmia (Irregular Heartbeat)
Arthralgias
Auditory Processing Issues
Back Pain
Band-like Pressure in Head
Bedbound
Bladder Control Issues
Bladder Pain
Blurry Vision
Bone Aches in Extremities
Bradycardia
Brain Fog
Brain Pressure
Brain Zaps (Electrical Shock Sensations in Head)
Bruising of Skin
Bulging Veins
Burning Sensations
Burning Tongue
Central Apnea
Central Sensitization
Chest Pain
Chest Tightness
Chills Without Fever
Clogged Ears
Cold Burning Feeling in Lungs
Cold Intolerance
Confusion
Constant Thirst
Constipation
Costochondritis (Chest Wall Inflammation)
Cough
Coughing Up Blood
COVID Tongue
Cracked or Dry Lips
Cranio-Cervical Instability (CCI)
Craving Salt
Delayed Onset of Symptoms
Dental Decay
Dental Problems
Depersonalization (Feeling Detached from Self)
Depression
Derealization (Feeling Detached from Reality)
Dermatographism (Skin Writing)
Diarrhea
Difficulty Swallowing (Dysphagia)
Disorientation
Double Vision
Dry Eyes
Dry or Peeling Skin
Dry Mouth (Xerostomia)
Dry Scalp or Dandruff
Dry Throat
Dyspepsia
Dyspnea
Dysmenorrhea (Painful Periods)
Epstein-Barr Virus Reactivation (EBV)
Ear Pain or Pressure
Electric Shock Sensations
Epistaxis (Nosebleeds)
Erectile Dysfunction (ED)
Erythromelalgia
Esophageal Spasms and Dysmotility
Exercise Intolerance
Extreme Pressure at Base of Head or Occipital Nerve
Eye Floaters
Eye Pain / Ocular Burning
Eye Stye or Infection
Eyelid Twitching
Facial Paralysis (Partial)
Facial Pressure or Numbness
Fatigue
Feeling Full Quickly When Eating (Early Satiety)
Feeling of Burning Skin
Feeling of “Hot Blood” Rushing to Face
Feeling of Being “On Fire”
Fevers
Food Intolerance
Gallbladder Disease and Gallstones
Forgetfulness
Gagging
Gastritis
Gastric Ulcers
Gastroparesis (Delayed Gastric Emptying)
GERD
Goiter or Thyroid Enlargement
Hair Loss
Hand or Wrist Pain
Headaches
Hearing Loss
Heart Palpitations
Heat Intolerance
Heavy Limbs
Hiccups
Hypertension / High Blood Pressure
Hot Flashes
Hyperacusis (Sensitivity to Sound)
Hyperhidrosis (Excessive Sweating)
Hyperosmia (Increased Sense of Smell)
Hypersensitive Skin (Tactile Allodynia, Skin Discomfort, or Pain to Light Touch)
Hypersomnia (Excessive Sleepiness)
Hyperthyroidism / Thyrotoxicosis
Hypoglycemia (Low Blood Sugar Episodes)
Hypothyroidism (Low Thyroid Function)
Hypotension (Low Blood Pressure)
Impaired Coordination
Inability to Cry
Inability to Exercise / Post-Exertional Malaise (PEM)
Increased Infections or Slow Recovery from Them
Intracranial Hypertension, Increased
Increased Sensitivity to Light (Photophobia)
Insomnia
Intermittent Paralysis or Limb Weakness
Internal Vibrations
Interstitial Cystitis
Irregular Periods or Menstrual Cycle Changes
Irregular Pulse
Irritability
Itchy Skin
Jaw Pain
Joint Pain / Knee Pain
Joint Swelling
Kidney Pain
Kidney Stones
Lack of Appetite
New Food Sensitivities
Laryngeal Pain (Pain in the Voice Box)
Ligament Laxity (Joint Hypermobility or Instability)
Leg Pain
Lightheadedness
Liver Pain or Discomfort
Livedo Reticularis (Mottled Skin)
Loose Skin
Low Blood Oxygen (Hypoxemia)
Low Libido / S*xual Desire Loss
Menorrhagia (Heavy Menstrual Bleeding)
Metabolic Syndrome
Lymph Node Swelling (Especially in Neck or Armpits)
Mood Disturbances and Mood Swings
Morning Aches and Pains
Mouth Sores or Ulcers
Multiple Chemical Sensitivity (MCS) / Odor Sensitivity
Muscle Aches
Muscle Loss (Atrophy)
Muscle Spasms
Muscle Twitching / Fasciculation
Muscle Weakness
Myocarditis (Heart Inflammation)
Myoclonus
Nail Changes (“COVID Nails”)
Nausea
Neck Pain or Stiffness
Neck Swelling
Nerve Pain (Neuropathic Pain)
Night Sweats
Nightmares
Numbness
OCD-like Symptoms
Olfactory Disturbances (Anosmia, Parosmia, Phantosmia, Hyposmia)
Orthostatic Intolerance (Worsening of Symptoms When Standing)
Osteopenia / Osteoporosis
Ovarian Pain
Painful Scalp
Painful S*x (Dyspareunia)
Panic Attacks
Paranoia
Paresthesia (Sensation of Skin Crawling or Tingling)
Pelvic Pain
Petechiae (Tiny Blood Spots Under the Skin)
Post-Exertional Malaise (PEM)
Postnasal Drip
POTS (Postural Orthostatic Tachycardia Syndrome)
Pruney or Wrinkled Skin on Fingers or Toes
Purpura
Racing Thoughts
Rash
Raynaud’s Phenomenon
Re**al Pain
Restless Legs
Runny Nose
Seizures or Seizure-Like Episodes
Sensory Processing Issues
Shoulder Pain
Sinus Pain or Congestion
Skin Discoloration (Purple Feet)
Sleep Apnea
Sleep Fragmentation and Vivid Dreams
Slurred Speech
Small Fiber Neuropathy (SFN)
Sneezing Fits
Sore Throat
Spikes in Blood Pressure
Swelling in Extremities (Hands, Feet)
Swollen Lymph Nodes
Syncope (Fainting)
Tachycardia (Rapid Heart Rate)
Tachypnea
Taste Disturbances (Ageusia, Dysgeusia)
Temperature Dysregulation
Temperature Lability / Low Temperature
Testicular Pain / Orchitis
Tics or Involuntary Movements
Tinnitus (Ringing in Ears)
Tooth Pain or Loosening
Tremors
Trigeminal Neuralgia
Unexplained Weight Gain
Unexplained Weight Loss
Urethral Pain
Urethrolithiasis (Urethral Stones)
Urticaria (Hives)
Vertigo
Visual Hallucinations
Visual Snow / Static-Like Visual Noise
Vocal Cord Dysfunction (VCD)
Voice Changes
Voice Hoarseness or Loss
Vomiting
Wheezing

INDEX
Abdominal Bloating

Abdominal Burning

Abdominal Cramps

Abdominal Pain

Abnormal heartbeat

Abnormal periods

Abnormal smell

Abnormal taste

Acid Reflux (GERD and Silent Reflux)

Activity (Cognitive or mental) as a trigger

Adrenal Exhaustion

Adrenaline Dumps

Adrenaline Surges

Ageusia

Air Hunger

Alcohol Intolerance

Allodynia

Amenorrhea

Anemia

Angioedema

Anhedonia

Anhidrosis

Anosmia

Anxiety

Aphasia

Appetite, low

Arrhythmia

Arthralgias

Ataxia

Back Pain

Balance issues

Band-like Pressure in Head

Beau’s lines

Bedbound

Belly pain

Bladder Control Issues

Bladder Pain

Bloating

Blood pooling in legs

Blue fingers

Blue toes

Blurry Vision

Bone Aches in Extremities

Bradycardia

Brain Fog

Brain Pressure

Brain Zaps

Breathlessness

Bruising of Skin

Bulging Veins

Burning mouth syndrome

Burning Sensations

Burning Skin

Burning Tongue

Chilblains

CCI

Central Apnea

Central Sensitization

Chemical Sensitivity

Chest Pain

Chest Tightness

Chest wall pain

Chills Without Fever

Clogged Ears

Cognitive activity as a trigger

Cold Burning Feeling in Lungs

Cold Intolerance

Cold room as a trigger

Concentration problems

Confusion

Constant Thirst

Constipation

Cortisol

Costochondritis

Cough

Coughing Up Blood

COVID Tongue

Cracked or Dry Lips

Cranio-Cervical Instability

Craving Salt

Dandruff

Delayed Gastric Emptying

Delayed Onset of Symptoms

Dental Decay

Dental Problems

Depersonalization

Depression

Derealization

Dermatographism

Diarrhea

Difficulty Swallowing

Disorientation

Dizziness

Double Vision

Dry Eyes

Dry lips

Dry mouth

Dry or Peeling Skin

Dry Scalp

Dry Throat

Dysautonomia mechanism

Dysautonomia Primary Symptoms

Dysgeusia

Dysmenorrhea

Dysmotility

Dyspareunia

Dyspepsia

Dysphagia

Dyspnea

Dyspnea on Exertion

Ear fullness

Ear Pain

Ear pressure

Ear ringing

Early Satiety

EBV

Electric Shock Sensations

Electrical Shock Sensations in Head

Emotional Instability

Endothelial dysfunction mechanism

Endothelial Dysfunction Primary Symptoms

Epistaxis

Erectile Dysfunction

Erythromelalgia

Esophageal Spasms

Estrogen deficiency

Excessive Sleepiness

Excessive Sweating

Executive function problem

Exercise Intolerance

Extreme Pressure at Base of Head

Eye Floaters

Eye Infection

Eye Pain

Eye Stye

Eyelid Twitching

Face Swelling

Facial numbness

Facial Paralysis

Facial Pressure

Fainting

Fasciculations

Fatigue

Feeling Full Quickly When Eating

Feeling of Being “On Fire”

Feeling of Burning Skin

Fermented products triggers symptoms

Fevers

Flashing lights in vision

Food Intolerance

Food sensitivities

Forgetfulness

Gagging

Gallbladder Disease

Gallstones

Gastritis

Gastroparesis

GERD

Globus

Goiter

Gut dysbiosis mechanism

Hair Loss

Hallucinations

Hand pain

Hard stools

Head pressure

Headaches

Hearing Loss

Heart Inflammation

Heart Palpitations

Heartbeat problems

Heartburn

Heat as a trigger

Heat Intolerance

Heavy Limbs

Heavy Menstrual Bleeding

Hiccups

High blood pressure

High carbohydrate meal triggers symptoms

Histamine intolerance mechanism

Hives

Hoarseness

Hormonal Imbalance Primary Symptoms

Hormone imbalance mechanism

Hot Blood

Hot flashes

Hyperacusis

Hyperhidrosis

Hyperlipidemia

Hyperosmia

Hypersensitive Skin

Hypersomnia

Hypertension

Hyperthyroidism

Hypoglycemia

Hyposmia

Hypotension

Hypothyroidism

Hypoxemia

IIH

Inability to Cry

Inability to Exercise

Inability to feel pleasure

Inability to Sleep

Inability to Sweat

Incontinence

Increased Infections

Increased Sense of Smell

Increased Sensitivity to Light

Insomnia

Insulin Resistance

Intermittent limb weakness

Intermittent Paralysis

Internal tremors

Internal Vibrations

Interstitial Cystitis

Intracranial Hypertension, Increased

Irregular heartbeat

Irregular periods

Irregular Pulse

Irritability

Itchy Skin

Jaw Pain

Joint Hypermobility

Joint instability

Joint Pain

Joint Swelling

Kidney Pain

Kidney Stones

Knee Pain

Lack of Appetite

Language problems

Laryngeal Pain

Leaky gut mechanism

Leg Pain

Ligament Laxity

Lightheadedness

Livedo Reticularis

Liver Pain

Loose Skin

Loss of smell

Loss of taste

Low Blood Oxygen

Low Blood Pressure

Low Blood Sugar

Low hemoglobin

Low Libido

Low Temperature

Low Thyroid Function

Low-Grade Fevers

Lump in throat

Lymph Node Swelling

Mast Cell Activation mechanism

MCAS / Histamine Primary Symptoms

Memory loss

Menorrhagia

Menstrual cycle changes

Mental Activity as a trigger

Metabolic Syndrome

Metallic taste

Microclots mechanism

Microclots Primary Symptoms

Migraines

Mitochondrial dysfunction mechanism

Mitochondrial Dysfunction Primary Symptoms

Mood Changes

Morning Aches and Pains

Morning headaches

Mottled Skin

Mouth Sores

Mouth Ulcers

Multiple Chemical Sensitivity

Muscle Aches

Muscle Atrophy

Muscle Loss

Muscle Spasms

Muscle Twitching

Muscle Weakness

Myocarditis

Myoclonus

Nausea

NDPH

Neck Muscle Pain

Neck stiffness

Neck Swelling

Nerve Pain

Neuropathic Pain

New Food Sensitivities

New-Onset Daily Persistent Headache

Night Sweats

Nightmares

No smell

No taste

Nosebleeds

Numbness

Obstructive sleep apnea

Occipital Nerve pain

OCD-like Symptoms

Ocular Burning

Odor Sensitivity

Olfactory Disturbances

Oligomenorrhea

Orchitis

Orthostatic Intolerance

OSA

Osteoporosis

Ovarian Pain

Pain in the Voice Box

Pain to Light Touch

Pain, back

Pain, jaw

Pain, joint

Pain, kidney

Pain, knee

Pain, leg

Pain, re**al

Painful Periods

Painful Scalp

Painful S*x

Panic Attacks

Paranoia

Paresthesia

Parosmia

Pelvic Pain

PEM

Petechiae

Phantosmia

Photophobia

Photopsia

Physical activity as a trigger

Poor coordination

Post-Exertional Malaise

Postnasal Drip

Postural Orthostatic Tachycardia Syndrome

POTS

Pruney skin on fingers or toes

Pulse, irregular

Purple feet

Purple toes

Purpura

Racing Thoughts

Rapid Heart Rate

Rash

Raynaud’s Phenomenon

Re**al Pain

Restless Legs

Retention, urinary

Ringing in Ears

Rotten Teeth

Runny Nose

Seizures or Seizure-Like Episodes

Sensation of Skin Crawling or Tingling

Sensitivity to Sound

Sensory overload

Sensory Processing Issues

S*xual Desire Loss

SFN

Shortness of breath

Shoulder Pain

Silent reflux

Sinus Pain or Congestion

Skin color changes

Skin Discoloration (Purple Feet)

Skin Discomfort

Skin Writing

Skin, itchy

Sleep Apnea

Sleep Fragmentation

Sleep problems

Slow Recovery from infections

Slurred Speech

Small Fiber Neuropathy

Smell problems

Sneezing Fits

Sore Throat

Spasms, muscle

Spikes in Blood Pressure

Standing as a trigger

Stress as a trigger

Sweating

Swelling in Extremities

Swelling, joint

Swollen Lymph Nodes

Syncope

Tachycardia

Tachypnea

Taste Disturbances

Temperature Dysregulation

Temperature Lability

Testicular Pain

Testosterone deficiency

Thirst

Throat tightness

Thyroid Enlargement

Thyroid hormone deficiency

Thyrotoxicosis

Tics or Involuntary Movements

Tinnitus

Tooth decay

Tooth loosening

Tooth Pain

Tremors

Trigeminal Neuralgia

Triggers

Triggers of symptoms

Triggers symptoms after meals

Ulcers in Mouth or Throat

Unexplained Weight Gain

Unexplained Weight Loss

Unrefreshed sleep

Urethral Pain

Urethrolithiasis

Urgency

Urinary frequency

Urinary incontinence

Urinary retention

Urinary urgency

Urticaria

Vertigo

Vestibular Dysfunction

Vibrations

Visual Changes

Visual Hallucinations

Visual Snow

Vivid Dreams

Vocal Cord Dysfunction (VCD)

Vocal fatigue

Voice Changes

Voice loss

Vomiting

Weak voice

Weakness

Weakness, muscle

Weight Gain

Weight Loss

Wheezing

Word finding difficulty

Word-finding ability

Wrinkled Skin on Fingers or Toes

Wrist pain

Xerostomia

12/27/2025

A work meeting leaving you bedbound for two days. Reading for 30 minutes triggering severe fatigue that feels exactly like physical overexertion.

Your brain's energy demands are just as real as your muscles'.

Your brain consumes 20% of your body's total energy despite being 2% of body weight. Cognitive work, concentration, decision-making, memory recall, requires significant ATP production. Your neurons fire. Neurotransmitters release. Ion channels pump. All energy-intensive processes.

Think of it like running two different apps on your phone. One is a simple calculator. The other is a graphics intensive video game. Both drain battery, but the game drains it much faster because it demands more processing power.

Mental exertion is your brain's "video game." It demands maximum mitochondrial output.

But Long COVID impairs mitochondrial function everywhere, including your brain. When you concentrate hard, your neurons demand more ATP. Your damaged mitochondria struggle to produce it. Oxidative stress builds. Inflammation cascades.

The result 12-48 hours later? The same post exertional malaise you get from physical overexertion. Severe fatigue, cognitive decline, autonomic symptoms, sometimes flu-like feeling.

And mental exertion triggers are harder to pace because they're less obvious. You can feel your muscles getting tired. But cognitive fatigue? It sneaks up. You don't notice you've crossed your threshold until you've crashed.

What helps is cognitive pacing (shorter work blocks with rest). Reducing multitasking. Minimizing decision fatigue. Supporting mitochondrial function. Tracking mental energy expenditure like physical energy.

Your mental crashes are real post exertional malaise. Your brain's mitochondria are impaired just like your muscles' mitochondria.

Treating the mechanism treats both physical and cognitive PEM.

12/27/2025

High blood pressure with a slow heart rate looks contradictory, but in Long COVID it is a classic autonomic signaling problem, not a heart problem.

Here is what is actually going on.

1. Baroreflex misfiring (most common reason)
Blood pressure sensors in the carotid sinus and aortic arch are supposed to fine tune heart rate.
When they falsely sense pressure changes, they trigger a reflex vagal response.

Result
Blood pressure stays high
Heart rate is inappropriately slowed

The heart is responding correctly to incorrect signals.

2. Sympathetic–parasympathetic mismatch
In healthy physiology, high blood pressure should be paired with appropriate sympathetic tone.
In dysautonomia, the system becomes uncoupled.

You can get
• Excess vascular constriction raising blood pressure
• Excess vagal signaling slowing the heart

This is not fight or flight.
It is loss of coordination.

3. Endothelial dysfunction driving pressure up
Endothelial injury causes abnormal vascular stiffness and nitric oxide dysfunction.

Result
• Blood vessels stay constricted
• Blood pressure rises
• Reflex pathways respond by slowing the heart instead of fixing the vessel tone

The problem is vascular signaling, not cardiac strength.

4. Hormonal contributions
Low cortisol, altered aldosterone, thyroid imbalance, or autonomic renin angiotensin disruption can all raise blood pressure while lowering heart rate.

This combination is common in post viral autonomic syndromes.

5. Why this confuses clinicians
High BP plus bradycardia triggers concern for primary cardiac disease or medications.
In Long COVID patients, cardiac testing is often normal because the issue is neurologic and reflex based.

Treating only blood pressure numbers often worsens symptoms if the autonomic imbalance is not addressed.

Bottom line
High blood pressure with bradycardia means the heart and blood vessels are no longer communicating properly.

This is a systems problem.
Not anxiety.
Not athlete conditioning.
Not primary heart failure.