Long COVID: Q&A with Dr. Lindsay McAlpine of Yale School of Medicine

Transcript

• 00:10Hello everyone.
• 00:11Today we are welcoming back
• 00:13Doctor Lindsay McAlpine.
• 00:14Lindsay was here for the
• 00:16Kindred Cafe in July,
• 00:17and she has kindly offered to
• 00:19come back and answer a few more
• 00:21of the questions that were in the
• 00:23chat when Doctor Lindsay McAlpine
• 00:25is a neuro neuroimmunologist and
• 00:27an instructor in the Division
• 00:29of Neurological Infections and
• 00:30Global Neurology at the Yale
• 00:32University School of Medicine.
• 00:34She started the Neuro COVID Clinic
• 00:35at Yale in October 2020 and
• 00:37sees patients with neurological
• 00:39issues related to long COVID.
• 00:41She is an investigator in the
• 00:42COVID MIND study at Yale and her
• 00:44research interests are related to
• 00:45the pathophysiology of cognitive
• 00:47impairment after COVID-19 using
• 00:49several modalities including MRI.
• 00:53A question for Doctor McAlpine if
• 00:55there is time, can small fiber
• 00:57neuropathy resolve over time or
• 00:58is it permanent for Progressive?
• 01:00What are some of the theories behind this?
• 01:02The 'cause, this common long
• 01:03COVID long back symptom?
• 01:08Yeah, so I think that's a important question
• 01:12because so many patients with long COVID
• 01:15are found to have small fiber neuropathy.
• 01:18So the first does it resolve over time?
• 01:22In a lot of cases it does resolve
• 01:26and in other cases it doesn't.
• 01:29Usually there's a complicating factor
• 01:31when it's not resolving like diabetes
• 01:34or pre diabetes can be another reason
• 01:37to have small fiber neuropathy,
• 01:39another disease that's damaging
• 01:43and affecting the nerves.
• 01:46Is it permanent or progressive?
• 01:48After COVID, in my experience
• 01:53it is worst at onset,
• 01:56so it's the worst right after the infection.
• 02:00Usually comes on within one to
• 02:03six weeks after the infection
• 02:04and that's the worst it gets.
• 02:07It doesn't usually progress unless
• 02:09you have another inflammatory
• 02:11influence causing progression.
• 02:13And what are the theories behind this?
• 02:16So one of the theories is that
• 02:21there is during the acute infection
• 02:24there's such significant inflammation
• 02:26that's triggered that it damages
• 02:29the small fiber nerves.
• 02:30The exact mechanism of the damage,
• 02:33we're not sure is that molecular mimicry.
• 02:36So do the small nerve fibers to
• 02:39the immune system look like the
• 02:41virus and therefore cross react?
• 02:44That's one of the thoughts.
• 02:46But what we think it is given the
• 02:49time of onset post viral autoimmune
• 02:52conditions almost always happen
• 02:55within the first one to 12 weeks
• 02:58after a viral infection.
• 03:00And so because it comes on in that
• 03:03window and is maximal at onset,
• 03:05it makes sense that it's an autoimmune
• 03:08condition that's triggered.
• 03:10And often we see that there are also
• 03:13auto antibodies that are developed
• 03:16Like I mentioned during the panel
• 03:19last time that the University of
• 03:23Saint Louis or Universe Washington
• 03:26University in Saint Louis has an
• 03:28excellent panel that tests for some
• 03:30auto antibodies that are linked
• 03:32with small fibro neuropathy.
• 03:36And you know that addresses one of
• 03:38the other questions that when when
• 03:42you have an autoimmune disease,
• 03:44every time you get a viral
• 03:47infection or any infection really,
• 03:50you can have worsening of your
• 03:52autoimmune symptoms because you're
• 03:54turning on and turning up and revving
• 03:56up the immune system and that's going
• 03:58to Rev up your autoimmune disease.
• 04:00So one of the other questions was that
• 04:03they got worse during viral infections
• 04:04after this that that makes a lot of sense.
• 04:09Thank you so much.
• 04:10Next question is related to migraine
• 04:12and face a recent appointment
• 04:14with an MECFS practitioner.
• 04:15It was proposed that the initial
• 04:17long COVID symptoms were atypical
• 04:19migraine that after persisting
• 04:21caused POTS a month later and all
• 04:23the other symptoms my husband has
• 04:25been bedridden since the fall and
• 04:27extremely severe at this point.
• 04:28Does the explanation of untreated
• 04:31persistent migraine track? So
• 04:34I think that in some individuals
• 04:37that untreated migraine is definitely
• 04:40considering contributing to long COVID.
• 04:45We've seen an increase in new migraines
• 04:49after COVID and also an increase in
• 04:52severity of migraines after COVID in
• 04:54people who have already had migraines.
• 04:57So as a neurologist we call almost all
• 05:00headache migraine because it is mediated
• 05:03through the same trigeminal ganglion
• 05:06which mediates pain in the brain.
• 05:09So I don't think that migraine is an
• 05:15explanation for all of long COVID.
• 05:18It's certainly
• 05:22is common in some of is commonly
• 05:26comorbid with some of the conditions
• 05:28that come on after COVID like pots,
• 05:31pots and migraine can be linked
• 05:33same with you know elderstand lows
• 05:36or chronic fatigue or mast cell
• 05:38and migraine are closely linked.
• 05:39So there's a connection but I
• 05:42don't think it's the entire,
• 05:45you know explanation.
• 05:47And so treating each of those
• 05:50individual conditions is what
• 05:52is going to kind of remove the
• 05:55roadblocks to recovery and making
• 05:57sure that each migraine is treated
• 06:00effectively is very important.
• 06:02You want to treat a migraine at the
• 06:04very onset of the headache before it
• 06:07ramps up into a a major painful attack.
• 06:13Some of the other questions include head
• 06:16pressure and pain at the back of the head.
• 06:20So we've seen quite a bit
• 06:22of occipital neuralgia.
• 06:23So the occipital nerves comes out
• 06:28of the neck and it comes through the
• 06:31neck muscles and tight neck muscles
• 06:33pinch the occipital nerve and then it
• 06:37causes this numbness, tingling pain
• 06:39in this distribution on each side.
• 06:42So we've seen that quite frequently as well.
• 06:46And then there's a question here about what,
• 06:47what's headache and what's migraine.
• 06:49So I think we call almost
• 06:51everything migraine.
• 06:52Typically a migraine can be associated
• 06:54with a bunch of other symptoms.
• 06:56So migraine can be associated
• 06:58with sensitivity to light,
• 07:00sensitivity to sound and smell.
• 07:03You become sensitized to everything.
• 07:05It's associated with nausea because migraine
• 07:09involves the vagus nerve which slows down,
• 07:12causes some gastroparesis as well and it
• 07:15also can be associated with neck discomfort,
• 07:18neck pain, irritability,
• 07:21word finding difficulty,
• 07:24what else specifically?
• 07:25Aura as well.
• 07:27So visual aura, sensory aura can all be
• 07:31involved and so migraine is is a syndrome.
• 07:33It's just not head,
• 07:35it's not just head pain.
• 07:36Next question.
• 07:42Next question is,
• 07:43any suggestions for screen sensitivity?
• 07:45Since COVID, I have developed
• 07:48atypical treadmill neuralgia and
• 07:50feel like I am in a sci-fi film.
• 07:53Looking at any screen through my right eye,
• 07:55sets the entire left side of my face on fire,
• 07:58even with my left eye closed.
• 08:00Incredibly debilitating.
• 08:00Can't work hard to function.
• 08:03Yeah. So I think when, when I was
• 08:06looking through a lot of the questions,
• 08:07I think this is really important
• 08:09because not everything that comes
• 08:12on after COVID is long COVID.
• 08:15So a lot of patients have other
• 08:18conditions that come on after long COVID.
• 08:21So I would call new trigeminal neuralgia,
• 08:24that's trigeminal neuralgia.
• 08:25We're not going to treat it any
• 08:27differently because it came on after
• 08:29COVID and I wouldn't put it in
• 08:31that bucket of long COVID either.
• 08:33And I think that's important
• 08:35because you want your physicians,
• 08:37your care team to treat that
• 08:39condition like that condition,
• 08:41no different because of COVID.
• 08:43And so trigeminal neuralgia is really
• 08:46painful, uncomfortable, awful condition.
• 08:48I'm sorry that happened.
• 08:50And there's a lot of different
• 08:52therapies you can try,
• 08:53making sure you get a full work up with
• 08:55imaging and everything is really important.
• 08:57And then going through, you know,
• 08:59just like any condition,
• 09:01it's important to try each thing and
• 09:04and see what works for you 'cause
• 09:06it's going to be different for each patient.
• 09:10One of the other things is that,
• 09:12you know,
• 09:12seeing patients with Yon Bray syndrome,
• 09:15which is a distal progressive numbness,
• 09:19tingling and weakness that develops,
• 09:23that is going to come on.
• 09:25We do see it after COVID,
• 09:26we do see it after the vaccines.
• 09:28We see it after any viral
• 09:30infection or vaccine.
• 09:31It has reports and it's an autoimmune attack
• 09:34of the myelin on the peripheral nerves.
• 09:38And so it it's triggered by the
• 09:41infection and then it comes on within
• 09:43a couple few weeks after the infection.
• 09:46And so if you're kind of falling into that
• 09:49long COVID bucket of after three months,
• 09:52then it's not going to be related
• 09:54to Guillain Barre.
• 09:55And it has a very classic symptoms
• 10:00and timeline too.
• 10:02So one of the other questions is
• 10:04a patient wrote in about being
• 10:07diagnosed with transverse myelitis.
• 10:10And again,
• 10:11I would say transverse myelitis can be
• 10:15triggered after COVID or after a vaccine,
• 10:19but I would not call it long COVID.
• 10:21It's transverse myelitis,
• 10:22it has its own set of work up,
• 10:26has its own set of treatments,
• 10:29and it's I wouldn't consider that long COVID.
• 10:33Let's see
• 10:36and same with the GAD 65 S GAD 65
• 10:42is an auto antibody that develops
• 10:45and it causes stiff person syndrome.
• 10:48So one of the patients said that
• 10:50was positive in both both their
• 10:52blood and their spinal fluid.
• 10:54And so I would say to that that's
• 10:57you know probably early stiff
• 10:59person syndrome and that warrants
• 11:01a full work up and treatment,
• 11:04so disease modifying therapy and close
• 11:09monitoring with a neuroimmunologist.
• 11:11And so I would take that approach.
• 11:15You know, when I see a patient,
• 11:17I'm always making sure that
• 11:19we're not missing something else,
• 11:21we're not missing another disease
• 11:23and just lumping the symptoms
• 11:26in with a bucket of long COVID,
• 11:28things that aren't long COVID.
• 11:31Yeah, next question.
• 11:32Thank
• 11:33you. That's a really important distinction.
• 11:37Next question, can you briefly
• 11:38mention the theories of what causes
• 11:40persistent neurological COVID
• 11:41symptoms and what traction each has,
• 11:44EG autoimmune reaction,
• 11:45persistent virus viral remnants, etcetera?
• 11:49Yeah. So I have a slide.
• 11:56So here is a figure from the
• 12:00publication Science by my mentor
• 12:04Doctor Sweeness Footage and one of our
• 12:08colleagues at the NIH, Doctor Avinath.
• 12:12You can see here that it kind of reviews
• 12:17the mechanisms of effect and so starting
• 12:23generalized neuro inflammation with
• 12:25track of trafficking of immune cells,
• 12:28cytokines and auto antibodies into the
• 12:31brain and activation of the microglia.
• 12:33We know this happens during
• 12:36the acute infection,
• 12:37but once the immune system
• 12:39is kind of turned down,
• 12:42to what extent is this persisting?
• 12:44We're not seeing ongoing cytokine
• 12:47elevations in the spinal fluid.
• 12:50And so it's unknown the extent of the
• 12:53persistent neural inflammation particular
• 12:56particularly in the absence of objective
• 13:00clear inflammatory lesions on MRI.
• 13:05We're not seeing that.
• 13:06So we're not see most,
• 13:08the vast majority of people with long COVID
• 13:12have completely normal clinical Mris.
• 13:16So
• 13:19antibody production within the spinal
• 13:22fluid in response to the virus and auto
• 13:26antibodies we've published on this.
• 13:29We found unique auto antibody
• 13:31signatures in the spinal fluid.
• 13:33We've also found auto antibodies
• 13:36to COVID in the spinal fluid.
• 13:39Extended portion of that is probably
• 13:42leaking over from the bloodstream
• 13:44into the spinal fluid and may or may
• 13:47not have a clinical effect because
• 13:50we see elevated antibodies in both
• 13:53our control subjects with no long
• 13:55COVID and in our long COVID subjects.
• 13:59So it's unclear.
• 14:01So there's limited, you know,
• 14:03evidence for the presidents of actual
• 14:06viral particles or proteins in the brain,
• 14:10very, very limited.
• 14:11So I think this is an unlikely scenario.
• 14:14Here the blood vessels is my
• 14:18main focus of interest.
• 14:20They may be damaged or dysfunctioned
• 14:23dysfunctioning due to endothelial
• 14:25activation which is the lining of
• 14:28the blood vessel and this cascade
• 14:32of Coagulopathy and in some cases
• 14:35leading to micro bleeds or stroke
• 14:38particularly in the acute infection.
• 14:40This is not seen as frequently in long COVID.
• 14:43So after three months after
• 14:45the acute infection,
• 14:46we're not seeing strokes
• 14:48or bleeds in the brain.
• 14:50But when we talked about before the
• 14:57dysfunction of blood vessels and
• 15:00withdrawal of oxygen from the tissues,
• 15:03that occurs in chronic fatigue syndrome where
• 15:06the blood that's going through the tissues,
• 15:08you're,
• 15:09you know,
• 15:10a chronic fatigue patient
• 15:11is only extracting half,
• 15:1250% of the oxygen and an individual
• 15:17without that would extract 80%.
• 15:20So that dysfunction of the
• 15:22diameter of the blood vessels and
• 15:24shunting at the tissue level may
• 15:27also be happening at the brain.
• 15:29So that would explain why
• 15:31there's such exquisite
• 15:35sensitivity. So the brain is a very
• 15:38sensitive organ to any dysregulation
• 15:40or disruption and function.
• 15:42So even if there's a little bit
• 15:44of disruption in the function of
• 15:46the blood vessels in the brain,
• 15:48I would expect there to
• 15:49be symptoms from that.
• 15:50And so that's my theory,
• 15:52but I have no proof for this.
• 15:55There is some preliminary evidence out of
• 15:59Harvard that there is cerebral hypoperfusion.
• 16:04And I think this all goes
• 16:06on the same spectrum.
• 16:08And what we're not seeing
• 16:11is objective frank strokes.
• 16:13So that is the good news.
• 16:15So there's subtle dysfunction but no
• 16:19severe lack of oxygen to the brain.
• 16:24Thank you so much. Yeah, next question,
• 16:28are there reliable tests available here
• 16:30in the US to diagnose micro clotting?
• 16:35We addressed this a little
• 16:37bit that at the last meeting,
• 16:38but we haven't found clear evidence
• 16:43of micro clots, actual clots in
• 16:46the tissue in the blood vessels.
• 16:48It's more the activation of the
• 16:52endothelial lining and subtle
• 16:54persistent vascular inflammation.
• 16:56There's a number of clinical blood
• 17:00tests that can tease this out.
• 17:03One of them I'm trying to think of
• 17:06a lot of them are research tests.
• 17:11C reactive protein can be a very general
• 17:15marker of inflammation of the blood.
• 17:18Elevated Von Willebrand factor has
• 17:21been shown to be elevated in acute
• 17:24COVID linked to endotheliopathy.
• 17:27There's there's a number of different
• 17:30markers that can be used both in research
• 17:32and clinically to tease this out.
• 17:35How are you diagnosing the vascular
• 17:37inflammation you described?
• 17:39Right, so it's in the in the blood
• 17:42we're we're using research tests and
• 17:45in the brain we're using also research
• 17:48tests sequences to look at subtle
• 17:51perfusion differences in the brain. Yeah.
• 17:58Next question. Do
• 18:01you have an experience opinion about
• 18:04HBOT following up on the theory
• 18:05of poor oxygen at the micro level?
• 18:11Yeah, So there have been some small
• 18:16promising studies that show that H Bot
• 18:20can improve fatigue and some of the
• 18:23neuropsychiatric symptoms of long COVID.
• 18:26I do think it's related to this
• 18:30chronic fatigue pathology.
• 18:31So the dysautonomia pathology,
• 18:34the one issue is that in patients
• 18:39who undergo H bot therapy,
• 18:41it improves while they're on it,
• 18:43which is, you know,
• 18:45and it time intensive therapy.
• 18:48But once it finishes,
• 18:50it doesn't seem to have a lasting
• 18:55recovery effect like like the DIS
• 18:58Autonomia PT exercise protocols do.
• 19:02Yeah. And then you know,
• 19:03one of the other thoughts
• 19:05is with severe fatigue,
• 19:06it's also important to look
• 19:08for those other things.
• 19:10So we'll talk about sleep next,
• 19:12but making sure that everybody
• 19:14has a cortisol test,
• 19:16making sure that there's
• 19:18no adrenal insufficiency,
• 19:20that's really important.
• 19:21And then there was another question here.
• 19:29I think it's important to a lot of
• 19:32patients come to me really wanting to
• 19:34know was it COVID that caused my post
• 19:38viral syndrome or was it something else?
• 19:40And I know that an A definitive
• 19:44answer would be helpful,
• 19:45would make patients feel better,
• 19:47but from my perspective it doesn't
• 19:51matter because this condition post viral
• 19:54syndrome can happen after anything, right.
• 19:58So it can happen after Mono CMV.
• 20:03You know, GYN infections any the
• 20:07flu parafluenza you know can happen
• 20:10after any inflammatory viral illness.
• 20:13And so I would say take what you
• 20:18have and what symptoms you have and
• 20:21focus on how to heal and get better.
• 20:24And that that answer is like something
• 20:26we can't always provide and doesn't
• 20:29won't necessarily change your treatment,
• 20:31if that makes sense.
• 20:32Have there been patients post
• 20:34COVID who you have sent for
• 20:36further evaluation for narcolepsy
• 20:38or autoimmune eccentral latest?
• 20:41Yes, sorry. Yeah,
• 20:43yeah. So we've seen and there were
• 20:45quite a few questions about sleep.
• 20:47We've seen a lot of sleep
• 20:49disorders after COVID.
• 20:50People seem to be much more
• 20:53sensitive to sleep deprivation
• 20:55and interruption after COVID.
• 20:58One of the first things that I do for
• 21:00anyone with sleep issues and cognitive
• 21:03issues is to send them for a Sleep
• 21:06Medicine evaluation with a sleep study.
• 21:08That's really important.
• 21:10We are finding a lot of new
• 21:13sleep apnea after COVID.
• 21:15I don't think COVID necessarily caused that,
• 21:18but it's just now you're
• 21:20going to have much more,
• 21:21many more symptoms from it.
• 21:23You're not going to be
• 21:24able to tolerate it well.
• 21:25And so sleep apnea is treated,
• 21:28whether it's central or obstructive,
• 21:30it's treated very similarly with a CPAP.
• 21:33So the continuous positive
• 21:36pressure machine overnight,
• 21:37a lot of patients balk at that,
• 21:40understandably so.
• 21:43But it improves the quality of sleep
• 21:47and the quality of life so much that
• 21:50almost everybody who gets it loves it.
• 21:53They take it everywhere, vacation,
• 21:55they have to come to the hospital,
• 21:56people bring their own machine,
• 21:58they love it.
• 22:00So I really encourage all my patients to
• 22:04give it a try to pursue the full work up,
• 22:07get treatment for sleep apnea.
• 22:09And then I've had patients
• 22:11convert their entire family,
• 22:13get their entire family diagnosed and
• 22:16treated and everybody feels a lot,
• 22:18a lot better.
• 22:19So I think that's a really important thing,
• 22:21getting treatment for insomnia,
• 22:23really important to treating the
• 22:26underlying anxiety or depression that
• 22:28might be contributing to insomnia.
• 22:30The gold standard therapy is
• 22:32cognitive behavioral therapy,
• 22:34a type of you know, psychology approach.
• 22:37It's wonderful.
• 22:38We have a wonderful team here that does
• 22:42CBT for insomnia and my patients love it.
• 22:45It's a really healthy approach to
• 22:48sleep and it gives you the coping
• 22:51tool tools to manage insomnia.
• 22:54Some of the medicines that
• 22:56I'll use one second
• 23:00or insomnia, one of the ones I use
• 23:03the most is probably Trazodone.
• 23:05It's well tolerated, lower doses,
• 23:08not habit forming and generates sleepiness.
• 23:12In addition to that,
• 23:15all of the sleep, hygiene things,
• 23:17so no blue light, no screens,
• 23:21cool bedroom wine down before bed.
• 23:24It's all of the lifestyle
• 23:27factors are so important.
• 23:29We can put medicine band aids on top of them,
• 23:33but if we don't change the
• 23:35underlying health, you know,
• 23:36create a healthy lifestyle,
• 23:37it's really hard to to medicate over
• 23:40that. Hi, I got the COVID shots.
• 23:42I have stomach issues since I got the shots.
• 23:44Now I have ticks going on.
• 23:46Plus this month alone I I was plus stutter.
• 23:51I was in the ER on July 9th.
• 23:55Yeah. Plus I stutter.
• 23:58So stutter and ticks. Yeah, it
• 24:02it's COVID itself can cause
• 24:06new psychiatric issues.
• 24:09Anxiety, depression, panic attacks.
• 24:11I've had patients who during
• 24:14their acute illness were,
• 24:17you know, suicidal and never
• 24:18been suicidal in their life.
• 24:19Like, there is objective evidence that
• 24:21it does alter the function of the brain.
• 24:25And then the experience of long
• 24:28COVID is so difficult that it's
• 24:31not surprising that people,
• 24:33in reaction to the difficult experience,
• 24:37develop anxiety,
• 24:38depression and other psychological disorders.
• 24:42I've seen it a lot, you know,
• 24:45new ticks and stutters.
• 24:47Sometimes people with stutter
• 24:48will have had it as a kid and
• 24:51then it comes back after COVID.
• 24:54Sometimes it's it's as a stress response to,
• 24:59you know, I think one of the other
• 25:03participants mentioned developing
• 25:05somatic symptom disorder,
• 25:08which is basically excessive anxiety about,
• 25:12you know,
• 25:13physical symptoms in their body,
• 25:15which again is an understandable
• 25:17response to having so many symptoms.
• 25:20Developing long COVID,
• 25:22you know,
• 25:23there's such an interplay between mood,
• 25:26cognition, sleep,
• 25:27function all well-being that you
• 25:30really can't tease those things apart.
• 25:34And so I really encourage all of
• 25:37my patients to address all of the
• 25:40psychological issues because they can
• 25:42be a big roadblock to healing and
• 25:44to feeling better because no one,
• 25:47well,
• 25:47I'm not and and certainly no one
• 25:50in our clinics is saying that
• 25:53any of this is in someone's head,
• 25:55but the suffering in your head
• 25:57can make your symptoms and make
• 26:00you feel a lot worse.
• 26:01And so I really encourage all of my
• 26:04patients who are struggling to get
• 26:07the help they need with therapists,
• 26:10psychiatrists,
• 26:10sometimes going on a medicine for
• 26:12six months to a year while you're
• 26:15going through this really struggling,
• 26:17you know this difficult time while
• 26:19you recover, it's not forever.
• 26:20You know, I I think it's really,
• 26:23really important.
• 26:24And and on on the same vein,
• 26:27I have seen quite a few patients with
• 26:30functional neurologic disorders,
• 26:32which is where neurology and psychology
• 26:35really kind of overlap and come together.
• 26:38Functional neurologic disorders are
• 26:41basically they're not volitional.
• 26:43Patients are not doing these
• 26:45things on purpose.
• 26:47There's no like awareness that this
• 26:50is on purpose, it's not on purpose,
• 26:52but it can come in many different ways.
• 26:55So it can be new tremors of a certain
• 26:59they're very distinct characteristics.
• 27:01So it's hard to describe,
• 27:02but tremors, seizure like events,
• 27:07lower extremity, weakness,
• 27:10trouble walking,
• 27:11these are all common ways that
• 27:14functional neurologic disorders develop
• 27:15and these things develop in response,
• 27:18typically to stress.
• 27:20The way that we describe it is it's
• 27:23a it's a dissociative disorder where
• 27:26your your mind and your body's
• 27:28experiencing stress, depression,
• 27:29anxiety, and it's difficult to cope with.
• 27:33Your subconscious doesn't know how
• 27:35to deal with it.
• 27:36And so this is how it comes out.
• 27:38It comes out as a new tremor,
• 27:39comes out as kind of complete dissociation,
• 27:42seizure like events.
• 27:43It comes out as difficulty walking.
• 27:46And so,
• 27:46you know,
• 27:47the number one thing for
• 27:49getting better from a functional
• 27:51neurologic disorder is
• 27:53insight, really insight into Oh yes,
• 27:56I have been, this has been really hard.
• 27:59I have not been feeling well.
• 28:00I've been dealing with so many
• 28:03other symptoms and issues.
• 28:04I it makes sense that, you know,
• 28:06I'm having a hard time and and
• 28:08one of the treatments is also
• 28:10cognitive behavioral therapy,
• 28:11so using relaxation and coping methods to
• 28:17address address the psychological issues.
• 28:19So we've seen that a lot in
• 28:22conjunction with long COVID too. Yeah.
• 28:27Thank you. I
• 28:28do think you know another question when
• 28:32it comes to like the somatic symptoms is,
• 28:36you know a lot of people have said
• 28:38they've had so much work up, they've had
• 28:41so many tests and they're all normal.
• 28:43You know in in this condition
• 28:45we expect them to be all normal.
• 28:47We, you know, you may have a
• 28:49positive tilt table test from POTS
• 28:51if you're lucky enough to get an
• 28:53invasive CPAP that would be abnormal.
• 28:55But we expect the MRI,
• 28:57the lab test to be normal and if
• 29:00you've had a thorough work up for
• 29:04all of the symptoms that you have,
• 29:06then usually I say to my patients we
• 29:10can stop looking and focus on recovery.
• 29:13So I think that's like a really hard
• 29:17balance is when to know when to stop
• 29:20going down the diagnostic pathway and
• 29:23turning into the healing recovery pathway.
• 29:27So you know working closely with your
• 29:30doctor to kind of figure out where
• 29:33that line is and then moving ahead
• 29:35with the with the therapies and the
• 29:38treatments that that work, yeah.