The Complications of “Long COVID” Part IV
Post-Vaccine Syndrome and Management & Treatment of Long COVID Symptoms
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To help further the discussion on Long COVID here’s an interview Dr. Mobeen conducted with Dr. Bruce Patterson and Dr. Yo. I’ll also provide a more recent, shorter presentation that Dr. Patterson gave at Georgetown University as well (this one is 50 minutes versus the 2 hour interview with Dr. Mobeen).
Before we proceed, remember that the proceeding information is intended to be informative and not medical advice. Also, remember that I am not a medical professional! Please consult a medical professional or physician in order to properly discuss Long COVID and Post-Vaccine Injuries. Nonetheless, this information may hopefully provide some useful insights and topics to discuss with a medical professional if you are seeking out advice on how to treat any of your symptoms. Act sensibly and make sure to collaborate the treatment options here with your own research.
But before we get to all of that, I would like to spend some time ranting on Vaccine-Induced Injuries and how these symptoms are so similar to those of Long COVID.
The Similarities of Long COVID and Post-Vaccine Injuries
If the symptoms of Long COVID are difficult to believe, Post-Vaccine Injuries (more readily named Post-Vaccine Syndrome, or PVS) are even more difficult to have properly assessed. In a massive global campaign to defend the safety and efficacy of these vaccines, in particular the DNA and mRNA vaccines, public health authorities have made it their goal to prevent the dissemination of any information that would undermine any attempts to get the entire world vaccinated. It’s only after billions of doses of these vaccines being provided are public health leaders finally discussing the possible adverse reactions, but even then these discussions tend to be narrow in scope and tend to only acknowledge the realities of myocarditis but not many of the other possible symptoms. This leaves many people who may present with headaches, fatigue, myalgia, or brain fog in the dark as to what may have caused these symptoms. In fact, it would not be a surprise if these people are considered to have Long COVID instead of suffering from vaccine-induced side effects.
The overlap in symptoms between Long COVID and Post-Vaccine Syndrome is very concerning. It suggests that similarities in pathology may be at the root of these symptoms. The main argument here is that the S1 subunit is the causative agent. Although I provide slightly tangential hypothesis that includes the production process of the spike protein, the spike protein clearly should not be overlooked in its role in causing many of these symptoms. Even though many studies of the spike protein were done in vitro usually using pseudoviruses, these studies have implicated the spike protein as 1. helping the virus to invade the blood-brain barrier, 2. helps promote a hyperinflammatory response, and 3. aids in the signaling of the Unfolded Protein Response and promoting ER Stress.
When people discuss concerns over the spike protein produced by the vaccine, one defense usually suggests that the spike protein produced by the vaccine is vastly different than the one produced by the virus. Strange, especially when these claims tend to come from people who claim to “follow the science”. You’ll notice that a lot of these “fact checkers” don’t actually engage with the science when discussing the reality of the vaccine’s spike protein. We can easily debunk these claims with two arguments.
One, by virtue of eliciting an immune response to viably target the virus, the spike protein’s vaccine must resemble the target antigen. Anyone who argues that these spike proteins are vastly different contradict the intentions of a vaccine. Clearly a spike protein that looks too dissimilar to the one in circulation would not produce an adequate immune response. It’s also quite ironic that those who have made these claims have not been outraged at a Wuhan-based vaccine that looks far too dissimilar to both Delta and Omicron. So much for “following the science”.
Another claim made is that, although they look similar, the vaccine’s spike protein is safe because it contains two amino acid substitutions that lock its conformation in place. Unlike the virus’ spike protein the vaccines produce a spike protein that has two glycine residues swapped for proline residues. Glycine and proline are “special” amino acids. They provide pivotal structural changes to a protein. Glycine is the smallest amino acid. It’s also the only achiral1 one which means that it is extremely flexible. Regions of a protein rich in glycine residues have a high level of movement, and these regions are usually pivotal for conformational changes such as when a protein binds to a receptor and needs to “clasp” onto the receptor. In the spike protein, the glycine residues help provide that “clasping” change in conformation.
Proline, on the other hand, is used to provide rigidity. It’s the only amino acid where the amine group is attached to the amino acid’s side chain. Not only does this provide a kink in a protein it also prevents the protein from moving within these regions. Essentially, the swapping of highly flexible glycine residues for rigid proline residues locks the protein in place.
Correction: As Brian Mowrey has pointed out in the comment section, the residues that were replaced were not glycine but in fact lysine (K) and valine (V). The swap to proline still stands as that change still locks the structure in place (note that it is a (K986P, V987P) change) by forcing a permanent bend within the alpha helix of the protein. Apologies for not looking into this change further.
Now, that would make this protein safer IF the intent was to stop the binding and clasping motion. Most arguments in favor of these vaccines’ safeness would argue that this locked conformation would prevent the spike protein from attaching to ACEII receptors and allowing fusion to host cells to occur. However, what tends to be overlooked in these arguments is that, with these vaccines, we are dealing solely with the antigen and not the virus. Therefore, any arguments that the vaccines are safe because they prevent viral entry are not only absurd but actually are not scientifically sound. Clearly these people can’t be bothered to notice the differences between a vaccine spike and a spike attached to the actual virus.
So the real argument here isn’t if the vaccine’s spike protein can latch onto ACEII receptors, the argument is whether binding alone to various receptors or tissues can elicit detrimental signaling pathways or cause its own damage to tissues and organs. In that sense, people must delineate the notions that the sole activities of the spike protein are to gain entryway into cells. Emerging studies suggest that more is at play here with the spike protein, and unless so-called “fact checkers” acknowledge this reality they are undermining the actual principles of science.
Long COVID is real, and Vaccine-Induced Syndromes are real as well. Those who stand to argue the realities of one without arguing the realities of the other are not grasping the processes required to understand the pathologies seen in those who are suffering from either.
When the Cure may be the Disease
If the spike proteins produced by the vaccines are the primary culprit for all of the symptoms of Post-Vaccine Syndrome, then we are essentially at an impasse. Paradoxically, the antigen that is intended to produce a protective immune response may also have its own deleterious effects to the host. This begs the question; if the thing that is intended to provide protection is also causing damage, can you correct for one without compromising the other? Put another way, is there a way to deal with the spike protein and the manufacturing of said protein that does not compromise the intended anti-spike immune response?
This question is a difficult one to answer. Many of you who have been vaccinated may have been told not to take any NSAIDs (non-steroidal anti-inflammatory drugs) after being vaccinated because the tapering of the immune response may not provide you with the proper immunity against COVID. By extension, any short-term attempt at suppressing possible vaccine injuries may end up leading to a lackluster immune response that may leave someone vulnerable. Essentially, high risk with low benefit.
If, on the other hand, both the spike mRNA and the spike protein itself become long-lived, the risk of long-term effects may be of high concern if left unchecked. If this is the case, then clinicians may want to examine the vaccines through a time-dependent response, such that patients should not try anything that may reduce the intended immune response by taking corticosteroids or NSAIDs, but that they may want to try taking something a few weeks afterwards to prevent the deleterious effects of persistent spike proteins. With the latter, treatment options may be similar to those of Long COVID, in which case many people may find benefits with discussing these treatment options with their doctors. Granted, it’s a risky proposition when one considers that some symptoms of Post-Vaccine Syndrome are immediate, in which case catching the symptoms before the immune response would be nearly impossible.
There’s still so much we don’t know about the virus, let alone the vaccines. However, medical professionals should do well not to downplay the realities of Post-Vaccine Syndrome. Just as real as Long COVID is, the medical profession should acknowledge the realities of vaccine injuries. Only then can patients receive the proper care that they deserve, especially from a profession that prides itself in “doing no harm”.
Treatment and Management Options
Because the actual causes of Long COVID and Post-Vaccine Injuries have not been fully elucidated, it’s a bit hard to suggest a possible cure-all. However, that doesn’t mean that many repurposed drugs will not be effective. Here, I’ll provide a bit of an overview as to how what management and treatment options there are.
In general, treatment and management should take a multi-pronged approach tailored specifically to the needs based upon the symptoms. That may mean a multiple treatment options or it may even refer to something as simple as training techniques.
Just like in the case of ME/CFS, clinicians should take care to consider the realities of both Long COVID and Post-Vaccine Syndrome. To this day many patients are left dismayed that their concerns are not properly addressed or acknowledged. Even if the symptoms are psychosomatic, it would be wise to properly address where the symptoms are coming from. For those who believe they may be experiencing symptoms of Long COVID and Post-Vaccine Syndrome, it may be important to take note of all of the symptoms, when they first emerged, and if they were in proximity to either a COVID infection or a vaccination. Open, transparent dialogue is the most important factor in understanding the origins of the symptoms in order to properly address them.
Along with acknowledgement would be proper diagnoses of Long COVID or Post-Vaccine Syndrome. Because the symptoms of LC or PVS are closely related to ME/CFS, it may be pertinent to delineate the two groups. In those who have persistent dyspnea, neurological impairment, or cardiovascular issues imaging techniques may find unresolved tissue and organ damage that would need to properly be addressed. Biomarkers may also be something to look for, especially since many presentations of LC or PVS are traced to excessive cytokine and chemokine levels. In particular, as Dr. Patterson noted in his presentation, certain interleukin biomarkers may be elevated in instances of PVS and may serve as a differential marker between LC and PVS. If concerns of persistent viral infection are warranted, genomic sequencing may be a more viable confirmatory tool over PCR. Patients and clinicians may also think about testing for reactivated viruses from the herpes family such as Epstein-Barr and herpes zoster. Various other diagnostic tools pertinent to the supposed symptoms may also be worth considering for more specific symptoms.
Most treatment options for both LC and PVS have targeted the inflammatory process. Usually typical treatment options for generalized inflammation include NSAIDs and corticosteroids such as prednisone. For those with anosmia, there have been suggestions that nasal spray corticosteroids may help shorten the duration of anosmia, although this option has been highly controversial.
In Oaklander et. al’s treatment protocol for neural inflammation both corticosteroids and intravenous immunoglobulin therapies were utilized:
Here, most patients treated with sustained IVIg, the primary treatment for inflammatory neuropathy, with preliminary evidence of effectiveness for dysimmune SFN,8 perceived improvement (e.g., Figure 1, eFigure 1, links.lww.com/NXI/A697). Some treated only with corticosteroids did as well; participant 3 reported that prednisone helped her toward 90% improvement and was discontinued only because of adverse effects. Others improved substantially without immunotherapy (e.g., case 17), documenting spontaneous recovery and need to individualize treatment decisions.
In the case of persistent coughs Song et. al. suggest neuromodulators/anticonvulsives to control for the sensory input based upon prior evidence:
Persistent cough in post-COVID syndrome might be driven by neuroinflammation leading to a state of laryngeal and cough hypersensitivity, which is the basis for chronic refractory or unexplained cough. Gabapentin and pregabalin, which are neuromodulators, have been shown to be effective in controlling chronic refractory cough.88, 89 This approach could be considered for the post-COVID syndrome, because these drugs might also be useful for other symptoms accompanying cough, such as pain, although they have the potential to worsen any cognitive dysfunction. Antimuscarinic drugs, such as tiotropium, could be used to control COVID-19 cough, because they can decrease cough sensitivity in acute viral upper respiratory tract infection.90 Similarly, speech and language therapy91 might help patients to recover, delivered as part of a multimodal therapy and recovery model in synergy with other aspects of pulmonary rehabilitation for the post-COVID syndrome.
Fluvoxamine may be a viable candidate due to its Sigma-1 agonistic effects and may be worth considering for generalized inflammation, but especially for neuroinflammation and signs of neurocognitive impairment and depressive symptoms.
Alternative remedies and supplements that provide anti-inflammatory properties may aid in treating both LC and PVS, although care must be taken to verify the effectiveness of these supplements, which may be affected by manufacturer and concentration. Some supplements include tumeric curcurim, ginger, melatonin, vitamins such as C and D3, omega-3 fats, and flavanoids such as luteolin and quercetin (the latter of which I have written about extensively). Again, these supplements should be verified for their possible effectiveness, but having an arsenal of at-home supplements may be beneficial for most, especially considering their relative safeness, level of accessibility, and that there are no concrete therapeutics for both LC and PVS.
Antivirals and Shingles Vaccine
Under rare circumstances where LC symptoms may be attributed to reactivated herpes viruses, antivirals are likely to be the best option. Proper diagnosis must precede, but typical antivirals such as acyclovir, valacyclovir, and famciclovir may help. For elderly patients who are more likely to be immunocompromised vaccination against herpes zoster may be worth considering as a preventative measure during and post-COVID infection, as well as pre-COVID vaccination, in order to prevent a coinfection from occurring, as both COVID infection and post-vaccination have been associated with lymphopenia (low lymphocyte counts), a possible explanation for herpes reactivation.
Management and Reduction of Comorbidities
It should be quite obvious now that the more comorbidities a patient has the worse their predictive outcomes are with COVID. The same applies to Long COVID, although there is yet to be evidence for any relationship between comorbidities and PVS. Strains on various organs placed by diseases such as diabetes and obesity already put the body in a compromised, inflammatory state. Although there’s no evidence to support weight reduction and management of blood sugar and cholesterol in alleviating LC symptoms, the reduced strain on the body and normalization of biomarkers may allow the body to properly restore normal functions. Even if this does not help with LC many other diseases are associated with high blood pressure, diabetes, and obesity anyways. Overall health and wellness, irrespective of its effects on LC, would greatly improve with proper management of underlying comorbidities.
Cognitive Behavioral Therapy (CBT)
CBT is a combination of both cognitive and behavioral therapy that attempts to remove negative thoughts and behaviors that either tend to “over-generalize” or “catastrophize” situations and events. It’s intent is to make people aware of their life-altering thoughts and behaviors in order to provide them the ability to change their perceptions for the better. Symptoms of depression, anxiety, insomnia, and loss of appetite may stem from drastic changes in lifestyle and social circumstances rather than COVID itself.
Lockdowns, fears over contracting COVID and spreading it to others, missing work due to illness, or concerns over people’s perceptions of your behaviors or illness all can contribute to feelings of depression and anxiety. If no underlying neurochemical imbalances or neuropathy are known CBT may help to alleviate some of the psychological symptoms one may be experiencing. Although usually done in a therapy session or through conversing with someone else, some at-home practices and techniques can be done to help as well. Some techniques include becoming conscious or mindful of negative thoughts and behaviors, and engaging in relaxing hobbies such as meditation. However, sessions with a therapist that can find the root of the stressors cannot be overstated. Here’s some more information from both the Mayo Clinic and StatPearls from NCBI.
Antidepressants and Sleep Aid
Pharmaceutical interventions may be another possible route for those experiencing depression, anxiety, and insomnia. Proper consultation with a physician can help find proper therapeutic options which may include antidepressants, anti-anxiety medications, and sleep aids. Again, Fluvoxamine should not be discounted as both an antidepressant and its overall anti-inflammatory properties. Melatonin may also help aid in sleep and is also an anti-inflammatory as well. Lack of proper sleep is strongly linked to depressive and anxious feelings. Americans are also known to not have proper sleep regimens as well. Proper evaluation should be done to get to the root of these problems and to see if medical interventions are necessary.
The GI tract is abundant in ACEII receptors, making it a highly tropic organ system for SARS-COV2. Extensive invasion and damage are likely to attribute to LC. Symptoms can include loss of appetite, diarrhea, bloody stools, and cramps. Typical over the counter medications may help alleviate minor symptoms until the GI can fully heal. However, more severe symptoms should be addressed by healthcare professionals. Because the GI is one of the largest reservoirs for microbes there may be concerns that SARS-COV2 may disrupt the microbiome and cause dysbiosis. The gut microbiome is involved with the production of many of our vitamin and also helps to regulate immune function, all of which may become disrupted by dysbiosis. Probiotic supplements and foods rich in live cultures may provide some benefit in that regard. However, I should note that the research surrounding probiotics is not conclusive. Evidence of the actual effects of probiotics on gut health are slightly controversial and their applications in clinical settings are not always effective. The strains of bacteria and their ratios within the gut are still somewhat unknown, and therefore even supplementation may not yield proper benefits if it is done with the wrong bacterial strain. Care must be taken to properly assess the most relevant probiotics if one is to consider this route.
Let’s face it; many of us have packed on the pounds since the start of 2020. Lockdowns, lack of access to gyms and outdoor recreational parks and centers, and constant food deliveries have not been kind to many people’s waistlines. Not only does this make people more susceptible to COVID, it may contribute to the exacerbation of LC as well. As things begin to return to “normal”, many people may still not be returning to their old exercise habits. Exercise has been extensively researched as one of the best ways of staving off diseases and can greatly improve mood, cardiovascular health, immunological health, and pulmonary health. Those who many be experiencing cardiovascular and pulmonary complications post-COVID should consult a medical professional before engaging in strenuous exercise in case it may exacerbate lingering symptoms.
Correction: waste lines was changed to waistlines.
Here’s an excerpt from Jimeno-Almazán et. al.:
The confinement, the subsequent perimeter closures of the cities and the limitation of urban mobility along with the cessation of all types of group activities, the interruption of non-professional team sports and many other recreational options related to movement, such as parks and leisure areas or swimming pools, have further deteriorated the condition of citizens. After the confinement, there has been a supposed return to normality, in which, on many occasions, previous activities have not been recovered, especially in people who has suffered COVID-19.
Therefore, it is necessary not only to recover physical exercise in the inactive population, but also to position it as a tool in the management of patients with post-COVID-19 syndrome. Given that exercise has been shown to be beneficial in multiple pathologies with which the post-COVID-19 syndrome shares similarities both in terms of symptoms and its possible pathogenic mechanisms, it is worth considering the potential favourable effect that this would bring in the recovery of these patients. Figure 3 illustrates the potential benefits of exercise on the most frequent clinical manifestations of post-COVID-19 syndrome.
Inflammation and damage of blood vessels are another area of concern. Prolonged inflammation of vascular endothelium (referred to by Dr. Patterson as endotheleitis) and damage through cytokines and persisting monocytes may attribute to many of the symptoms of both LC and PVS. Two treatment options, provided by Dr. Yo and Dr. Patterson, as well as the FLCCC I-Recover protocol suggest the use of Atorvastatin and Maraviroc.
As the name implies, Atorvastatin is a statin (lowers cholesterol). The suggested mechanism of action, as described by Dr. Patterson, is to use a statin to target the production of fractalkine. Fractalkines are chemokines that attract various white blood cells such as monocytes to areas of damage and inflammation. They aid in the inhibition of apoptosis of monocytes, causing these cells to live far longer than required. Therefore, statins that reduce the levels of fractalkines may promote monocyte apoptosis (cell death) which would reduce inflammation.
Maraviroc is traditionally used as an antiviral against HIV. It operates as a CCR5 antagonic by binding to the CCR5 receptor and inhibiting other cells and pathogens from utilizing this receptor for attachment and cell entry. Both HIV and monocytes bind to the CCR5 receptor, so the use of a CCR5 antagonist would prevent monocytes from binding to the walls of blood vessels and producing an inflammatory response. In a general sense this would imply that other statins and CCR5 antagonists may be beneficial as well. However, keep in mind that these drugs tend to be expensive and come with many side effects. Be sure to fully discuss with a physician the benefits and risks of such a therapeutic regimen.
Although the field of Long COVID is fairly new, plenty of other protocols exist out there. I will note two additional protocols below. Know that the inclusion of these protocols should not be seen as an endorsement and are, once again, intended to inform.
One such protocol comes from the FLCCC (found here) which is a collaborative effort by various doctors:
The approach outlined in the I-RECOVER Management Protocol is a consensus based on a collaboration led by Dr. Mobeen Syed (“Dr. Been”), Dr. Tina Peers, and the FLCCC Alliance. Given the lack of clinical treatment trials of Long Haul COVID-19 Syndrome, these recommendations are based on the pathophysiologic mechanisms of COVID-19 and post-viral illnesses along with our collective experience observing profound and sustained clinical responses achieved with the treatment approach.
Some of the treatment options provided above are listed within the FLCCC’s protocol as well. Keep in mind that many of these treatments, including the ones I indicated above, have not been extensively researched, so there are many caveats to the proposed protocol.
At a time when COVID therapeutics are heavily limited, treatment options Long COVID are likely to bring up dead-ends just as often, possibly even more. So what can we make of the situation when any attempt to offer treatments gets chastised for spreading misinformation and false hope?
I came across this news article while looking up information on Fluvoxamine where the “controversial” doctor group was touting unproven Long COVID treatments.
I hope that my article from Sunday has prepared you all to meet these types of articles with skepticism. Many people won’t make it past the headline of a news article, so of course you should include the highly controversial “horse dewormer” drug in the title to evoke emotions.
There are a few other points that are made in the article that are worth pointing out:
"Recently I saw the FLCCC Long COVID 'protocol' & oh boy is this some crazy non-evidence based prescriptions: HIV meds, steroids, diuretics, & of course ivermectin," Dr. Nick Mark, an intensive care unit doctor in Seattle, wrote on Twitter.
"What concerns me is FLCCC presenting 'protocols' as proven treatments for long COVID," he added. "Throwing 20 medications (9 are prescription) at a problem with minimal (or no) evidence is irresponsible. As we will see, this is both unethical & likely harmful."
I will continue to lament that Twitter and other social media platforms are not good places to try to engage in discourse. What’s striking here is that this “Dr. Nick Mark” couldn’t even be bothered to elaborate on why these drugs are bad. Steroids being an issue? Steroids are one of the biggest go-to therapies out there for Long COVID! Nearly all of the references to treating Long COVID suggest using corticosteroids as a main line of treatment. Again, why make such a slanderous claim without providing any actual evidence to back up the claim?
You’ll also see this remark of “HIV meds” as a point of contention. I’ve had many problems with people referring to PAXLOVID’s dangers because of the inclusion of an HIV medication when many discussions have not described what that HIV medication is (it’s the P450 inhibitor Ritonavir, which I have speculated may improve Ivermectin’s effectiveness). The same could be said here, where Dr. Mark believes that throwing out the term “HIV meds” somehow undermines the drug’s actual mechanism of action. Just to point it out again, the HIV medication is a CCR5 antagonist and the intent is to prevent monocytes from binding to the lining of the endothelium and causing inflammation. Between his argument and mine which one justifies the use of Maraviroc (Note: this does not mean to use it, nor is it intended to inflate my ego. Just make sure that when you hear arguments valid points are made in said arguments.)?
Please read the article for yourself and parse the information. See if it provides anything of substance, or is serving as a hit piece without any proper evaluating of the drugs being described. Ironically, compared to many of the treatments in the papers I have seen these treatment options are rather conserved.
Just like with all therapeutics don’t take the word of anyone online, including mine or anyone within the mainstream press. Always make sure to evaluate the information on its merits, and always make sure to do your own research! Become an informed and active player in your own health.
The last additional protocol is one referred to me by subscriber Paul R. It’s an herbal-based remedy for both COVID infection and Long COVID. It comes from Dr. Stephen Harrod Buhner’s website. The protocol can be found in this pdf starting on Page 59 for Long COVID.
Note: Paul R. as commented that he has used Dr. Bhuner’s protocol to treat COVID patients with success. I cannot attest to the effectiveness of the protocol, nor do I know his position medically, but that should provide some perspective from someone who is seeing these protocols actively being used.
Edit 3/16/2022: Paul has expanded a bit more and has stated that he became an herbalist in his retirement and that his wife is a practicing MD who has used herbal remedies. Again, take this with a grain of salt but hopefully this provides even further context.
Now, I have skimmed over the protocol and it’s very extensive. Dr. Buhner actually does a good job of summarizing many of the different pathologies of COVID. However, I will admit that many of the herbal remedies have gone over my head (curse that Latin naming!). One point of concern is that many of the regimens provide serving suggestions and not dosages. This is a problem considering that manufacturers will have different concentrations of said herb.
I have also stated that the list of herbal remedies is extensive. In fact, probably too extensive. There’s quite good deal of offerings for individual symptoms. Take into account that many suffers of Long COVID may experience quite a few symptoms and a patient may require quite a good deal of remedies that may be hard to source or may become costly. I also have no way of validated the actual effectiveness of said remedies. The supplements I listed above within the anti-inflammatory section are supplements that I have, to some extent, been able to research for myself. However, I have not been able to look up all of the herbal remedies listed within that document. Because of that I can’t provide my own assessment of many of these therapeutics.
When looking at this document please do so with a discerning eye. Make sure to look up anything that you are unaware of and look for additional information from reputable sources, especially any studies that may validate the intended use of said herbs.
Things to Consider
Even as much of the pandemic begins to wind down there will be many people who continue to suffer symptoms of Long COVID. As a push for more vaccines continue (a 4th dose is now being considered for the elderly…) more people are likely to come forth with symptoms akin to Post-Vaccine Syndrome. Many of these people need to have their symptoms acknowledged by medical professionals, especially for those who’s symptoms after vaccination are being undermined by the narrative of the medical establishment. As many people’s symptoms will differ, clinicians should tailor treatment and management towards the needs of the patient focusing predominately on a multi-disciplinary, individual-based approach. People should also keep in mind that many behavioral and lifestyle choices may be responsible for exacerbated symptoms as well. Management of stress and anxiety, weight, comorbidities, and exercise should be considered as easy, freely accessible approaches. Hopefully more research will further the list of possible options.