Post-COVID and post-vaccination syndrome from the perspective of anthroposophic medicine – symptoms and treatment options

A growing number of people are affected by a post-COVID syndrome with often long-lasting, significant impairment of their health. Different pictures with prolonged hyperinflammation, damage and functional restriction of the musculature, the heart, the nervous system and the sensory organs occur. A larger group of somewhat younger patients exhibit symptoms of postviral myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS). These patients often had a more mild course of COVID-19. This article presents aspects for an understanding the disorder as well as a multimodal treatment concept of anthroposophic medicine.

Acute COVID-19 disease: the first four weeks of the coronavirus illness.

Persistent post-COVID syndrome (PPCS; ICD-10: U09.9) or long COVID: usually used synonymously with post-COVID, especially for symptoms that persist for longer than 12 weeks (1, 2). Residual symptoms/permanent damage or post-infectious symptoms existing from four weeks after the onset of the disease.

The severity of the acute phase and the triggering mutation of the pathogen do not correlate with the frequency and severity of long COVID. Three months after the onset of the disease, around 8 to 15% of all registered adult COVID patients report persistent complaints (3). These complaints occur much less frequently in childhood (4, 5). With regard to the frequency of severe post-vaccination syndromes (SAE), figures of between 0.4 and 0.8% are currently available (6).

Patients with severe symptoms show a high incidence of complex post-intensive care syndrome (PICS), the first signs of which may already appear in the acute phase. Approximately half of patients receiving intensive care experience a long COVID symptom (7).

The frequency, duration and extent of long-term pulmonary sequelae, immunosuppression and general impairment of quality of life are significantly related to the severity of the acute phase (8).

People over the age of 55 and with pre-existing conditions (known risk for severe COVID-19 disease progression: distress, exhaustion, depression, anxiety disorder, overweight, etc) are affected with significantly greater frequency and severity (9).

Competitive sportspeople also seem to be more affected (10). The frequency of other symptoms does not show such a clear correlation with the course of the disease, the level of inflammatory laboratory parameters or the severity of the acute disease.

Children seem to be affected by post or long COVID significantly less. Because of many asymptomatic courses in children (11), only preliminary assertions can be made (12). In children, too, pre-existing conditions can favour long Covid symptoms (4, 5). Still unclear, as they have been little studied, are the psychosocial consequences of a long lockdown.

Cardinal symptoms

• Tiredness/fatigue/general weakness,
• Breathlessness/dyspnoea, especially on exertion, including a feeling of constriction and chest pain with or without objective restriction of lung function (obstructive/restrictive),
• Palpitations without objective impairment of cardiac function;
• Headache, especially during/after exertion;
• Cognitive disorders (concentration, memory, "brain fog", etc.);
• Anxiety can accompany all of the above disorders in specific ways (see below).

Symptoms may present as a dry irritating cough, in the form of pain (head, muscle, joints, chest) and myopathy (CIM). With cardiac involvement: acute myocardial infarction, microinfarctions, ventricular or atrial fibrosis with ischaemic/non-ischaemic cardiomyopathy, myocarditis, symptomatic/subclinical dysfunction, various arrhythmias. Hair loss and various exanthema may occur on the skin.

In children, the main symptoms are fatigue, sleep disorders, taste and smell disorders and headaches.

Despite the frequent gastrointestinal complaints in the acute phase, they appear less frequently in persistent post-COVID syndrome (PPCS). However, severe gastrointestinal motility disorders are described.

The most common long-term neurological disorders (PCND) include: sleep disorder, dizziness, taste and smell disorders (13), polyneuropathy (CIP), ischaemia/apoplexy due to endothelitis and coagulopathy, autoinflammatory demyelination, encephalitis (14). The central nervous system seems to be affected more than the peripheral.

The most common cognitive and mental disorders include: memory impairment, impaired concentration, fuzzy thoughts ("brain fog"), stress intolerance, anxiety (15) and depression, post-traumatic stress disorder (PTSD) (16), obsessive-compulsive disorder (OCD), subjective feelings of suffering and a deterioration in quality of life (17, 18). Here, nocebo effects that are attributable to pandemic measures such as social distancing must also be taken into account (19, 20). Ten to 15% of those affected take psychoactive substances, 10% have suicidal thoughts.

Pathopsychology

Different pathomechanisms lead to post-COVID and post-vaccination syndrome (PC/PV):

1. The largest group of patients (approx. 80% with PC/PV) forms GPCR autoantibodies (= adrenergic agonistic autoantibodies). The spike protein or the protein fragments (through the mRNA vaccines) lead to antibody formation. The spike protein binds to ACE2 receptors (an adrenergic receptor/GPCR receptor). Immunological mimicry leads to the formation of autoantibodies (AAbs) in some patients, which not only recognise the spike protein, but also the adrenergic receptors (α1, β1, β2, ACE2/AT1, ET1 (endothelin), M2 (muscarinic)). These GPCR AAbs bind to the receptors and lead to stimulation (= agonistic effect). This binding can last for approx. 1 to 3 weeks and thus much longer than the physiological adrenergic substances. This "permanent stimulation" leads to an energy depletion of the cell. The different receptors and GPCR AAbs trigger different stimulations and functions in the organs and thus show a diverse clinical picture (21).
2. Approx. 8 to 15% of PC/PV patients exhibit spike protein persistence (so-called spicopathy) (22). The spike protein itself is highly thrombogenic and is also the antigen for the formation of GPCR AAbs. A subtype of spike persistence is the sole detection of spike protein in monocytes (peripheral blood monocytes PBMC). These are non-classical CX3CR1 monocytes, which survive longer than "normal" monocytes and can have a pro-inflammatory effect. These pro-inflammatory monocytes activate vascular endothelial growth factors (VEGF, => vasodilation), which leads to the symptoms of "internal pressure", cognitive problems and migraines. These non-classical monocytes are activated by physical activity, which may explain the exercise intolerance in spike protein syndrome patients. CCR5 inhibitors such as Maraviroc can inactivate these activated monocytes within a few days. This also quickly reduces vascular inflammation.
3. Microthrombotic dominant course (in 5 to 15% of patients): here the disturbance of capillary blood flow through so-called microthrombi and sludge formation in the capillaries of the various tissues is to the fore. The cause may be spike persistence (23), endothelitis due to ET1 AAbs (belong to the group of GPCR AAbs) (24, 25, 26), or complement activation (27, 28) respectively anti-platelet factor 4 (29, 30). Nailfold capillaroscopy is of great diagnostic importance here (31).

With regard to the pathophysiological processes, two polar tendencies are evident in severe courses:

• Persistent inflammation (endothelitis, myositis, myocarditis (with elevated serum parameter: CRP, D-dimers, LDH)), increased thromboembolic events (32).
• Fibrosing stiffness in the lungs and other tissues, chronic proliferative inflammation with fibrosis.

Immunologically, both the triggering virus (persistent reservoirs, viral fragments/spike proteins, reverse transcription into the human genome) and autoantibodies and immune regulation disorders can play a role here. An excessive first phase up to a so-called cytokine storm can be followed by a similarly excessive reaction, such as the compensatory anti-inflammatory response syndrome (CARS) and the persistent inflammation, immunosuppression, catabolism syndrome (PICS).

Persistent inflammation-related damage can occur in the lungs and airways (33). Innervation disorders and weakened respiratory muscles may also contribute to complex respiratory insufficiency after COVID (34).

Myocardial lesions occurring in the heart are already signalled in the acute phase by elevated troponin levels. Myocarditis, right heart strain, renin-angiotensin axis dysfunction, coagulopathy, neurovegetative influences and systemic prolonged hyperinflammation can lead to rhythm and conduction disorders, microfibroses and cardiomyopathies.

Endotheliitis and disorders of the blood-brain barrier play a significant role in damage to the nervous and sensory systems.

Diagnosis

What is required is an individualised medical history, which also includes the time before the development of COVID, and an appropriate to full physical examination, which can be supplemented by specific chemical laboratory and functional diagnostics (pulmonological, cardiological, neurological). The change in quality of life can be evaluated using questionnaires (such as SF-36 or EQ-5D) or management-of-daily-life instruments. After the initial staging, regular follow-up examinations and a final examination are indicated.

Differential diagnostics:

1. Determination of GPCR AAbs
   • The determination of clinically relevant GPCR AAbs is complex, as simple ELISA detections show no correlation to biological activity (e.g. IMD Laboratory). Biological test systems (bioassay) are required for the detection of GPCR AAbs, where the serum of patients is analysed for functional GPCR AAbs using embryonic rat heart cells (embryonic cardiomyocytes) (providers in Germany: E.R.D.E.-LABOR, https://aak-diagnostik.de/Einsendeschein.pdf; Cell-Trend; Berlin Cures). Due to the strong and long binding of GPCR AAbs to the tissue receptors, the serum concentration can only be determined semi-quantitatively, as they fluctuate due to movement, heat, etc. The following GPCR AAbs should be determined: α1- & AT1- & β1- & β2- & M2- & ET- & ACE2 AAbs.
   • (The various GPCR-AAbs usually also lead to organ-specific disorders:
     β2 and M2 => ME/CFS; β1/2 and M2 => Cardiac symptomsM POTS, RR fluctuations;
     α1 and ACE2 =>: Vascular alterations; ET1 => Endothelitis; β1 => Glaucoma, etc.).
2. Spike protein persistence/spicopathy
   • The currently leading laboratory in Germany for the detection of spicopathy/spike protein persistence is the MMD Laboratory in Magdeburg (https://mmd-labor.de/de/service/Auftragsformulare/index.php: Order form X). The tests for spike protein in plasma/serum, in the immune cells (PBMC) and in exosomes are relevant. The other analyses in other body fluids are reserved for special questions.
3. Microthrombotic dominant course
   • The clinical picture usually shows livid and cold acras, especially when the arms hang down. Nailfold capillary microscopy is the diagnostic method of choice (31): typical findings are ectatic capillaries up to megacapillaries, tortuosity and variations in calibre with also elongations of the capillaries, branched and tufted capillaries, sludge, oedema up to thrombosis. ET1 AAbs, spike protein in serum/PBMC, complement system and anti-platelet factor 4 should be analysed for the genesis of a microthrombotic course.

Extended understanding of disease from the perspective of anthroposophic medicine

A significant role in post-COVID and post-vaccination syndrome is played by disorders and dissociations in the patient's fabric of forces. These normally proceed in a dynamic equilibrium between dissolving and hardening tendencies (35). Post-COVID (and post-vaccination) can be seen as being triggered by an incompletely progressing – "warm" – acute inflammation, which then turns prematurely into a chronic – "cold" – inflammation. In 10 to 15% of PC/PV patients, chronic inflammation with spike protein persistence and chronic recurrent infections and/or a degenerative, hardening (sclerosing) tendency dominate and persist, which can lead to mental and physical exhaustion and is accompanied by a weakening of generative vital processes. In extreme cases, there is an extensive loss of muscular strength and deterioration after any exertion (post exercise malaise/PEM).

The decisive factor is whether, especially at night, during sleep, the inflammatory degenerative tendency recedes in favour of vital generative processes. This day-night rhythm can be severely disrupted in post-COVID patients. From an anthroposophical perspective and therapeutic experience, the focus here is on strengthening of the warmth organisation (I-organisation) in order to achieve the turn from persistent inflammatory processes to a day-night rhythm with nightly predominant generative processes (36).

Other, often younger patients suffer predominantly from a post-viral dissociation of their bodily vitality. The therapy is primarily aimed at helping patients to use the power of their individuality to direct their organism again, to perceive themselves, to utilise their vitality and to be able to be receptive to mental impulses. It is also about overcoming both the psychological alienation/dissociation from our own body and the clear feeling in some patients that their individuality is cut off from the spiritual sphere.

What is normally little effort proves exhausting for many. Even breathing loses its naturalness. Dyspnoea and fatigue are often accompanied by anxiety. Not infrequently, there are also cognitive limitations in the ability to think, concentrate and memorise. Some patients say that they experience something alien within them that feels different from other infectious diseases they have been through. They frequently feel powerless and paralysed inside.

Conventional standard treatment

The strategy includes the following steps: evaluation of the course of the acute phase, staging, screening of comorbidities, assessment of prognosis, formulation of the treatment plan with full involvement of the informed patient (37, 38, 39).

The treatment of PC/PV syndrome depends on its clinical severity and the pathophysiological cause. Severe courses with ME/CFS, myoclonus and PEM (post-exertional malaise) can make it almost completely impossible to increase dosed performance in rehabilitation therapy (crashes).

The spike protein is the antigen for GPCR AAb formation, so if the spike protein persists, it must be treated, as without antigen elimination, GPCR AAb elimination makes no sense, as the GPCR AAb would form again.

Treatment of spike protein persistence in serum

The following treatment regimen has proven to be the best option for spike protein in serum as a 4-fold therapy:

1. Ivermectin 0.2 mg/kg body weight, tablets divided into 2 doses per day. Take from day 1 to 8 and from day 21 to 28.
2. Nattokinase 2 x 2000 FU (freely available in shops, on the Internet) 2 x 1 capsule daily for 4 weeks.
3. Wobenzym®, 2 x 4 capsules daily for 4 weeks.
4. ACC® long 600 mg, 2 x 1 capsule daily for 4 weeks.

In a small series of three patients, the administration of a mixture of two different neutralising monoclonal antibodies (Ronapreve®) also showed clinical success (40).

Treatment of spike protein persistence exclusively in the PBMCs

The detection of spike protein exclusively in peripheral blood mononuclear cells (PBMC) involves special monocytes (see CX3CR1 monocytes above) that can be treated with CCR5 inhibitors such as Maraviroc (Celsentri). People weighing more than 40 kg take 2 x 300 mg Maraviroc for 14 days for spike protein levels up to 50 pg/ml in the PBMC; for higher concentrations, it is recommended to take 2 x 300 mg Maraviroc for 4 weeks (41, 42, 43). This indication is an off-label use prescription.

Treatment of severe PC/PV syndrome with GPCR AAb detection

It is important to determine the GPCR AAbs in bioassays and not as a pure ELISA. Furthermore, the clinical picture and symptoms of the detected GPCR AAbs should correlate with the organ deficiencies (see above). The most efficient treatment for the elimination of GPCR AAbs in severe PC/PV syndrome is immunoadsorption apheresis (IA) with filters from Miltenyi (TheraSorb®) or Fresenius (Globaffin®). Here, 5 IAs should be carried out at intervals of 2 to 3 days. A clinical response is achieved in approx. 70% and the control tests for GPCR AAbs are negative after 4 to 6 weeks. An increase in the efficiency of IA can be achieved through whole-body hyperthermia treatments (WBHT) between the IAs. Since large quantities of GPCR AAbs are bound in the tissues, an increased release of GPCR AAbs from the tissues can be achieved by WBHT with body temperatures of 39–39.5°C and a larger quantity can then be filtered out in the IA.

In very severe cases – patients who have been bedridden for more than two years, Bell score 0–20% and many GPCR AAbs – it has been shown that even 2 x 5 IA cycles are not always able to remove all GPCR AAbs from the body (despite reliable spike protein elimination), as these are present in the tissues in too high a concentration and the controls again showed high levels of GPCR AAbs in the plasma after 4 weeks. Future studies will have to show whether B cell depletion (Rituximab (44, 45, 46) or Ofatumumab (47)) with subsequent IA is more successful in these severe cases.

The biotechnology company Berlin Cures is currently conducting a phase II trial with an aptamer for the elimination of GPCR AAbs in patients with high (2-GPCR AAb levels and ME/CFS with a FACIT-F score <34, which is showing impressive clinical results in some cases.

Treatment of microthrombotic PC/PV syndrome

The primary treatment should depend on the genesis of the microthrombotic process. In the case of spicopathy, this must be treated (see above). In the case of endothelitis with GPCR AAbs of ET1, this AAb must be treated with IA. If the cause cannot be treated, symptomatic treatment can be carried out using platelet aggregation inhibitors (ASA, clopidogrel) through to combinations and the use of new oral anticoagulants (NOAC) or direct oral anticoagulants (DOAC); in very severe cases, H.E.L.P. apheresis with washing out of the microthrombi has also proved successful (48, 49). These H.E.L.P. apheresis treatments are mostly used repeatedly and repeated after 1 to 6 weeks.

Drug therapy

Pharmacotherapy is based on the established spectrum and corresponds to the organic permanent impairment or respective functional disorders.

Non-drug therapy

Cardiopulmonary rehabilitation measures such as breathing techniques (e.g. inhalatory muscle training) (50, 51), breathing trainers (e.g. tri-ball system) are carried out with professional physiotherapeutic support. With incremental exertion, monitoring of heart rate and oxygen saturation may be indicated.

Psychological/psychotherapeutic, neuropsychological (e.g. olfactory training), neurological, psychiatric rehabilitation measures (cognitive training, etc.) may be indicated up to and also during reintegration/ability to work (52).

Sport/strenuous physical exertion: even in an asymptomatic course or mild acute phase, a break of two to four weeks is necessary, in a symptomatic course at least four to six weeks.

From a social psychiatric perspective, protective elements play an essential role: social contacts, support opportunities, resources, secure livelihood, employment, recreational opportunities, basic social hygiene and medical care.

Supportive measures to help isolated patients look after themselves are essential (outpatient clinics, hotline, etc.).

Principles of sustainable integrative treatment

Integrative anthroposophical treatment is multimodal and sees itself as an extension of standard conventional treatment. It serves to support the forces of self-healing and self-regulation on a physical-physiological, psychological and mental-spiritual level. The resource analysis on the physical, psychological and spiritual level is an essential part of the treatment planning.

1. Warmth: The patients show a picture of stagnation of inflammation and/or fibrosis. The therapeutic stimulation of body temperature (I-organisation) enables the self-regulatory processes to intervene again on all levels. The patient's self-perception can be directly addressed through warmth. At first, many patients do not feel the inner lack of warmth. By strengthening and supporting the warmth organisation through appropriate clothing, external applications, self-active treatment methods and anthroposophical medicinal products (e.g. mistletoe therapy, see below), patients experience a more intensive access to their own corporeality (embodiment) again. If fibrosing stiffness in the lungs and other tissues and chronic proliferative inflammation are prominent, a sustained warming treatment is the determining therapeutic principle. This allows the vital forces in the metabolic system and in the limbs to become "tangible" again for the patients. At the same time, the dyspnoea fades, especially when there are few limitations in the measured lung function.
   • Whole-body hyperthermia (Heckel bed) – Indication: In patients with immunosuppression of the T-cells and weakness, inability to generate fever even with mistletoe therapy, whole-body hyperthermia (WBH) can be helpful. Likewise, WBH is a supportive therapy for severe post-COVID/post-vaccination syndrome in the elimination of GPCR AAbs by means of immunoabsorption apheresis to remove GPCR AAbs from the tissues before the IAs (see 4. Conventional therapy below). Target body temperature: 39.0°C with subsequent warmth build-up (plus endogenous temperature rise of 0.3 – 0.5°C). Even after an IA series with prolonged recovery from symptoms despite GPCR AAb elimination, WBH can be used to good effect.
2. Respiration: The objective here is to reintegrate and harmonise on a physical and mental level the disruption of respiration and life rhythms, which have become one-sided and taken on a life of their own, and which can be accompanied by typical anxieties. The treatment can support a deepened exhalation into the world as well as a deepened inhalation into the inner self. Especially for overcoming persistent inflammatory processes, a therapeutic reinforcement of self-regulation is necessary on the psychological level. Here it is essential that the patient feels emotionally accepted and understood and is initially relieved of mental and physical stressors that have taken on a life of their own. Care and self-care, rhythmisation of everyday life with regular breaks, individually appropriate, moderately self-active and artistic therapy methods (see Principles 5 and 6) can open up new access to emotional experiences.
3. Fluids and circulation: At the level of the life processes, the primary concern is toning and rhythmisation in order to overcome the pervasive weakness and heaviness. Morning rosemary washes tone the circulation and strengthen the day-night rhythm. External treatments such as the yarrow liver compress (53) stimulate body awareness via the skin, directly promote inner vitality and can improve sleep quality. A revitalisation of the microcirculation is achieved through rhythmical massage therapy, the revitalisation of body awareness and deepening of the sleep-wake rhythm through rhythmical Einreibung. Through activity, such revitalisation can be achieved through forest bathing (54) and/or eurythmy therapy. Stabilising a healthy daily rhythm with adequate breaks is essential. The rhythm of meals contributes significantly to this. A diet of organically grown fruit and vegetables, regular freshly cooked hot meals and sufficient food breaks support the patient's vitality. Bitters promote vitality and generative processes and strengthen the interaction between soul and body. Lastly, anthroposophic medicines specifically stimulate the vitality of individual organs.
4. Regeneration of tissue disorders: Treatment of impaired sensory functions (smell and taste disorder/alteration) with anthroposophical medicines and mindfulness-based olfactory training. Organ damage – e.g. in the lungs, cardiovascular system and kidneys, and functional organ disorders such as "brain fog" – can be treated supplementarily with anthroposophical medicinal products and eurythmy therapy.
5. Self-activity: A person's own limits must be carefully observed and only expanded gradually, otherwise there can often be a prolonged collapse in the person's own strength. Situations in which conscientious patients are under the impression that they are obliged to make a greater effort are particularly risky, which is why they should be advised as a precautionary measure to check themselves, before engaging in any activity, as to whether they are ready to perform it. It is helpful with PC/PV syndrome to have a four-week interval in which the focus is on therapy and reorientation and the workload is consistently scaled back.
6. Psychosomatic aspects: Initially, the focus is on actively reshaping a person's own life balance. Exercises to strengthen self-awareness (sensory exercises, mindfulness exercises) and mindful encounters with nature are helpful. Talking therapy and psychotherapy, artistic therapies and eurythmy therapy offer possibilities to effectively support the finding of the new balance in life. Anthroposophical therapeutic speech can provide effective support for breathing disorders. It is always important to consider the individual resources of the patient.
   • The removal of anxiety has a central role to play. To overcome the alienation from our own corporeality, it is essential to promote trust in our own corporeality through external treatments. Organ-related treatments such as heart compresses with Aurum/Lavandula comp. ointment, abdominal Einreibung with Oxalis oil, kidney compresses with ginger and foot baths with lavender can be considered here for example (52). Patients who were already prone to anxiety and depression before they developed COVID are more likely to show long COVID symptoms. Art therapies are particularly recommended for them, such as modelling, in order to strengthen the relationship with their own corporeality.
7. Biographical and spiritual aspects: It is important to support the patient in developing a new perspective. Here, first small steps are also important in the first instance. It is a matter of the patient finding their own measure anew and thus transforming the experience of the illness into a growth crisis of their own personality. Thus the patient can find their way out of the feeling of being a victim of the disease. Here it is essential to replace notions of achievement adopted from outside (from others) with more individualised goals. Spiritual and religious aspects can be of significance depending on the individual relationship with them.

1. Warmth organisation – medication for general weakness, fatigue

Anthroposophical mistletoe treatment is not only used in oncology but also offers a very effective way of stimulating the warmth organisation and vitality in non-oncological clinical pictures, thus strengthening the patient's self-regulation (53, 54). Here the dosage should be selected in such a way that it does not overtax the patient. The more delicate and the weaker the constitution of the patient, the more cautious the dosage should be at the start of mistletoe therapy (see below). Suitable mistletoe host trees are

• hawthorn (Crataegus) especially in weakness of the cardiovascular system,
• lime mistletoe (Tiliae) for intensive warming, especially in weakness in the lung area and the immune system,
• maple mistletoe (Aceris) for vitalisation of the metabolic system,
• birch mistletoe (Betulae) for depressively tinged exhaustion and to vitalise the kidney/adrenal system,
• pine mistletoe (Pini) for disorders of the nervous and sensory system.

Preparations that can be considered here are:

• ABNOBAViscum Crataegi, Aceris, Betulae, Pini: 0.02 mg 2 x/wk, after 8 amp, followed by 0.2 mg 2 x/wk SC. For fragile or very weakened patients, start with D6 – D20 amp and gradually increase the concentration
• HELIXOR P Series Pack I: 1 amp 2 x/wk, repeat if required
• ISCADOR P Series O: 1 amp 2 x/wk, followed by Series Pack 1
• Iscucin® Crataegi, Tiliae, Pini Potency Series I WALA: 1 amp 2 x/wk SC Potency Series I, repeat if required

This treatment can be supplemented by potentised gold and meteoric iron (Ferrum sidereum), especially in cases of anxiety and depression:

• Aurum D10/Ferrum sidereum D10 amp WELEDA, 1–3 x/wk SC or
• Aurum D12 trit WELEDA: 1–2 x/d 1 saltsp
• Ferrum sidereum D20 tab WELEDA: 1–2 x/d 1 tab
• Ferrum siderum Aurum/Quarz WALA

Fatigue in the context of chronic persistent inflammatory processes / in post-viral syndrome:

• Ferrum hydroxydatum 50% trituration, Apotheke an der WELEDA: 1 x ¼ – ½ levelled teaspoon in the morning
• Ferrum hydroxydatum 5% trituration WELEDA: 1–2 saltsp 3 x/d, (usually over 2–3 months)

For disorders of the warmth organism, general weakness, also in adolescent patients, as well as specifically after thrombotic/thromboembolic events

• Kalium aceticum comp. D6 amp, trituration WELEDA: 1 amp 1 x/d. SC or 1 saltsp 3 x/d

For conspicuous feelings of cold, circulatory insufficiency the following have a quickly invigorating and warming effect:

• Camphora D1 WELEDA: 5–10 gtt in water 1–3 x/d
• Camphora oleum D3 amp WALA: 1 amp 3 x/wk – 1 x/d. 1 amp IM alternatively aqueous SC

For persistent symptoms (weakness, cold, chronic "cold" inflammation):

• Quartz D60 amp WELEDA: 1 x 1 amp SC every 4–8 wks

2. Respiration

In case of a protracted course of COVID-19 pneumonia and weakness:

• Bryonia/Stannum amp WALA: 1 amp/d SC (between the shoulder blades, upper arm or in the upper abdomen)

For cough, loss of appetite, persistent inflammatory processes in the lung tissue, exhaustion:

• Roseneisen/Graphit pillules/amp WALA: 1 amp 3 x/wk SC / 10–15 pillules 2–3 x/d

For persistent dry cough and roborating:

• Verbascum comp. WELEDA: 20 gtt 3 x/d

For persistent signs of inflammation, mucus and tissue remodelling, also in the case of disorders of lung perfusion, s/p pulmonary embolism:

• Pulmo/Mercurius amp WALA: 1 amp 3 x/wk SC

Also suitable for inhalation in cases of persistent mucus congestion and coughing:

• Pulmo/Tartarus stibiatus I amp WALA: inhale up to 1 amp/d with 2 ml NaCl 0.9% or 1 amp 3 x/wk to daily SC

3. Cardiovascular system

For exhaustion, circulatory and blood pressure regulation disorders, tachyarrhythmias, possibly also sleep rhythm disorders, perceived pressure in the heart area, depression:

• Cardiodoron® drops WELEDA: 10–25 gtt 2–3 x/d

For myocardial involvement, in elderly patients with a tendency to arterial hypertension, mild heart failure in myocardial relaxation disorder, in cardiac arrhythmias:

• Cardiodoron®/Aurum comp. WELEDA: 10–15 gtt 3 x/d (contains i.a. Arnica, Aurum and Formica in D10)

Additionally for myocarditis:

• Cor/Aurum II amp WALA: 1 amp 1 x/d – 2 x/wk SC

For exhaustion, chronic persistent pain, post-viral burnout syndrome:

• Crataegus/Ferrum sidereum/Saccharum tostum amp WELEDA: 1 amp 3 x/wk SC

For arterial hypotension, dizziness, tendency to faint, feeling of weakness and coldness:

• Skorodit Kreislauf pillules WALA: 10 pillules 2–3 x/d
• Skorodit Kreislauf inject amp WALA: 1 amp 3 x/wk – daily SC

For s/p thrombotic events, weakened circulation in the venous area and general weakness, also in young patients

• Kalium aceticum comp. D6 amp / trituration WELEDA: 1 amp 1 x/d SC or 1 saltsp 3 x/d

4. Gastrointestinal system

For appetite disorders, nausea, indigestion:

• Absinthium D1/Resina Laricis D3 dil WELEDA: 10 gtt 3 x/d before meals, also counteracts a tendency to infection

alternatively:

• Bitter Elixier WALA: 1 teaspoon to tablespoon 3 x/d (alcohol-free)
• Amara drops WELEDA: 3 x 15–20 gtt before meals
• Enzian Magentonikum WALA: 3 x 1 teaspoon before meals

5. Musculoskeletal system

For myalgias, muscle weakness:

• Magnesium phosphoricum acidum D6 WELEDA: take 50 gtt 1 x/d dissolved in water spread throughout the day
• Plantago Primula cum Hyoscyamo amp WELEDA: 1 amp 2–3 x/wk SC or 1 amp per os daily
• Primula Muskelnähröl WALA: apply locally
• Arnica cum Cuprum Oleum WELEDA: externally

6. Sensory and nervous system

For loss of smell, disorders of the sense of smell:

• Bulbus olfactorius D5 amp WALA: 1 amp 3–7 x/wk SC (or per os for children) combined with olfactory training
• Jaspis D6 – D12 trituration, e.g. Apotheke an der Weleda: 1 x 1 saltsp daily

For loss of taste:

• Topas D15 amp WALA (D12 extemporaneous production): 1 amp 3 x/wk SC or 10 gtt/pillules or 1 saltsp trituration 1 x/d

For headache, weakness:

• Ferrum/Quarz Kapseln WELEDA: 1 cap 1–3 x/d, if required also with iron deficiency
• Ferrum sidereum comp. amp WELEDA or Ferrum/Sulfur comp. WALA: 1 x/d – 2 x/wk SC in the neck area
• Arnica, Planta tota D6 dil/pillules WELEDA/ WALA: 10 gtt/pillules 3 x/d, acutely 5–10 gtt/pillules up to half-hourly

For “brain fog”, cognitive weakness and disorders (memory, ability to concentrate), headache during cognitive exertion:

• Helleborus niger D12 amp WALA, HELIXOR: 1 amp 1–3 x/wk SC, 5–7 pillules 1–2 x/d
• Scleron® tab WELEDA: 1 tab 1–2 x/d

For shooting neuralgic pain in the extremities, the skin surface, burning pain (superficial):

• Aconit Schmerzöl WALA

7. Sleep disorders

For difficulties falling asleep and staying asleep:

• Valeriana comp. pillules WALA: 7–15 pillules 1 x/d in the evening

alternatively

• Calmedoron® Tr. Weleda, 15 – 20 gtt 1 x/d in the evening
• Bryophyllum 50% trit WELEDA: (in case of severe vital exhaustion) 2 saltsp at night
• Bryophyllum Argento cultum Rh D3 WELEDA: 20 gtt at night

8. For vital weakness, depression and emotional irritability

• Aurum/Apis regina comp. amp, pillules WALA: 1 amp 1 x/d – 2 x/wk SC; 10–15 pillules 3 x/d

complementary or alternatively for depressively tinged exhaustion and weakness:

• Aqua Maris D3/Prunus spinosa D5 amp WELEDA: 1 amp 3 x/wk SC

can be supplemented with

• Levico D1 (D3) drops WELEDA: gradually increase from the initial dose of 5 gtt per day to the target dose of 20 gtt per day and continue for as long as necessary
• Levico comp. pillules WALA: 10–20 pillules 1–2 x/d
  
  

Composition of the medicinal products mentioned: Kalium aceticum comp. Dil. D6: Kalium carbonicum, Acetum vini destillatum, Antimonite, Crocus sativus tincture, Spiritus e vino, Corallium rubrum. Verbascum comp.: Cetraria islandica, ethanol. Decoctum Ø, Achillea millefolium, Flos, ethanol. Infusum Ø, Pimpinella anisum, ethanol. Decoctum Ø, Verbascum densiflorum, Fructus immat. dil. D2. Cardiodoron: Ethanol. Digestio (1:3.1) from Onopordum acanthium, Flos rec., produced with 1% Hyoscyamus niger, herba rec. Ø, ethanol. Digestio (1:3.1) from Primula veris, Flos rec., produced with 1% Hyoscyamus niger, herba rec. Ø. Cardiodoron®/Aurum comp.: Donkey thistle ethanol. Digestio, Arnica montana ex planta tota D10, Formica rufa D10, Hyoscyamus niger ex herba mother tincture, Aurum metallicum praeparatum D10, Primrose blossoms ethanol. Digestio. Skorodit Kreislauf pillules/inj.: Camphora Dil. D3 aquos., Hypophysis bovis Gl Dil. D7, Prunus spinosa e floribus et summitatibus ferm 33d Dil. D5, Skorodit Dil. D5, Veratrum album e radice ferm 33c Dil. D3. Bitter Elixier WALA: Gentian roots (Gentianae luteae radix), Wormwood herb (Artemisiae absinthii herba), Ginger roots (Zingiberis rhizoma), Calamus roots (Acori calami rhizoma), Black peppercorns (Piperis nigri fructus), Sugar. Amara drops: Gentiana lutea, ethanol. Decoctum, Taraxacum officinale, Salvia officinalis e foliis siccatis, Achillea millefolium herba, Juniperus communis, Centaury extract; Masterwort root decoction, wormwood extract, chicory extract. Ferrum sidereum comp.: Ferrum sidereum Dil. D8, Quartz Dil. D20, Sulphur Dil. D6. Scleron: Plumbum mellitum trit D12 (Plumbum mellitum basic substance: produced from lead, honey and cane sugar). Valeriana comp. pillules: Sulfur aquosum D24, Valeriana officinalis ferm 33c D2, Calcium carbonicum Hahnemanni D6, Phosphorus D24. Calmedoron drops: Avena sativa Ø, Coffea tosta, ethanol. Decoctum Dil. D60, Humulus lupulus Ø, Passiflora incarnata, Valeriana, ethanol. Decoctum Ø. Aurum/Apis regina comp. pillules: Apis regina glycerol extract D5, Avena sativa ferm 33c D2, Strychnos ignatii ferm 35b D4, Hypericum ex herba ferm 33c D2, Acidum phosphoricum D4, Aurum chloratum aquosum D6. Levico comp.: Hypericum ex herba ferm 33c D2, Prunus spinosa ferm cum ferro D2, Levico stark-Wasser aquosum D2.

Principle 1: Strengthening the warmth organisation

Warmth applications have a primary role to play, as they promote the harmonising intervention of the warmth organisation, especially in patients with a fibrosing form of the disease or fatigue with a feeling of cold.

• Warm foot baths (55), 1 x/d in the morning
  • with oak bark, have a fortifying and structuring effect
  • chestnut foot bath especially for venous circulation disorders, feeling of heaviness in the legs, muscle pain
  • with rosemary tea or bath milk have a vitalising effect.
• Kidney compresses with ginger powder, also have a harmonising effect on breathing, 1 x/d for 5 consecutive days, then 1–3 x/wk,
  • for procedure see https://www.pflege-vademecum.de/ingwer.php?locale=en.
• Kidney Einreibung with Red Copper ointment WALA for patients who are anxious, little weakened in vitality, but have little emotional access to their condition.
• Beeswax packs on individual hypothermic, cold-sensitive areas of the body.
• The pentagram Einreibung in anthroposophical nursing supports reorientation for the vital body out of the warmth organisation.
• Whole-body hyperthermia under inpatient conditions.
• Oil dispersion baths, for procedure see https://www.pflege-vademecum.de/odb-grl-oel.php

Principle 2: Harmonisation of the breathing

• Yarrow lung compress for residual lung damage 1x/d for 5 consecutive days, then 1-3 x per week,
  • for procedure see https://www.pflege-vademecum.de/sg-luw.php.
• Upper abdominal compress (diaphragm compress) with rosemary copper oil 1 x/d for 5 consecutive days, then 1–3 x/wk: deepens and slows the breathing, improves diaphragm mobility, relieves cramps, also in fibrosing changes of the lungs.
  • For procedure see https://www.pflege-vademecum.de/rosm-ku-zfw.php.

Principle 3: Fluid and circulation

• Yarrow liver compress for vital weakness (if required Millefolium 10% ointment WELEDA CH), 1 x/d on 5 consecutive days, then 1–3 x per week,
  • for procedure see https://www.pflege-vademecum.de/schafgarben_leberwickel.php.
• Diaphragm compress with rosemary copper oil, 1 x/d for 5 consecutive days, then 1–3 x per week,
  • for procedure see https://www.pflege-vademecum.de/rosm-ku-zfw.php.

Principle 4: Regeneration of tissue disorders

• Thorax Einreibung with rock salt + 3 gtt rosemary oil, for fibrosing pulmonary changes 1 x/d on 5 consecutive days, then 1–3 x per week.
• To stimulate the anabolic metabolism in general yarrow liver compress, 1 x/d for 5 consecutive days, then 1–3 x/wk,
  • for procedure see https://www.pflege-vademecum.de/schafgarben_leberwickel.php.

Principle 5: Psychosomatic disorders, pain

• To support embodiment in general: Diaphragm compress with rosemary copper oil, 1 x/d for 5 consecutive days, then 1-3 x/wk,
  • for procedure see https://www.pflege-vademecum.de/rosm-ku-zfw.php.
• For posttraumatic symptoms: Pentagram Einreibung with Aurum / Lavandula comp. ointment WELEDA on three consecutive days,
  • for procedure see https://www.pflege-vademecum.de/aurum_lavandula_salbe.php.
• Invigorating and rhythmising action: Rosmary foot bath 1 x/d in the morning and lavender foot bath 1 x/d in the evening in alternation.
• Head: Formica D1 WELEDA as spray 1:5 or Arnika tincture 1:10 spray 2–3 sprays over the head every 2 hours until improvement occurs. Application is also possible as a head cover.
• Chest: Back Einreibung with Solum oil WALA to open the rearward space.
• Heart: Atrial appendage or organ Einreibung with Aurum / Lavandula comp. cream WELEDA) for impairment of mental functions, "brain fog", for functional heart complaints, anxiety.
• Stomach: Oxalis upper abdominal compress/Einreibung following traumatic experiences, see alsohttps://www.pflege-vademecum.de/oxalissalbe.php.
• Muscle/joint pain: Einreibung with Aconite Nerve Oil WALA.
• Feeling of exhaustion: Oil dispersion baths with prunus, rosemary.

Body therapy

The basic therapeutic approach of rhythmical massage therapy is to strengthen the organism's own powers of self-regulation. In the context of an international expert group for rhythmical massage therapy, specific treatment concepts for people suffering from long COVID were documented, presented in a symptom overview, and treatment recommendations were derived.

Download: Treatment concepts of rhythmical massage therapy

By varying the strokes, the quality and the selection of different areas of the body according to the findings, a therapy unit is structured in such a way that the specific symptoms of the illness can be addressed individually. It comprises a maximum of 30 minutes here. Overall, however, longer therapy units, more than six treatments in a row, are recommended. The goals are to strengthen the warmth organisation, harmonise breathing and circulation, regenerate tissue disorders and alleviate psychosomatic complaints and pain.

Suitable substances are

Solum oil WALA, Oxalis oil (e.g. Oxalis e planta tota W 10%, Oleum WALA). Peat oil with wood sorrel (Oxalis) WANDIL, arnica oil (e.g. Arnica, Flos H 10% WELEDA), rosemary oil (e.g. Rosmarinus, Oleum aethereum 10% WALA), prunus oil (e.g. Prunus spinosa e floris W 5%, Oleum WALA etc.), lemon balm oil (e.g. Melissa ex herba W 5%, Oleum WALA etc.), thyme oil (e.g. Thymus Oleum aethereum 5%, WALA), ginger oil (e.g. Ginger Massage Oil LICHTERDE), peat camomile oil (e.g. WANDIL), peat arnica oil (e.g. peat oil with arnica blossom WANDIL).

Movement therapies

• Endurance training (walking, Nordic walking or jogging) 3 x/wk, preferably in nature. The intensity and duration should be adapted to the given situation.
• Spacial Dynamics can be used especially for neurological movement disorders.
• Eurythmy therapy is presented here in greater detail as an example.

Eurythmy therapy is a holistic, self-activating, movement-oriented mind-body therapy (MMBT) within anthroposophic medicine which, with the help of movement exercises with arms, legs and the whole body (56), harmonises dysfunctional, vital-emotional and intentional processes in the human organism (57), comparable with Traditional Chinese Medicine TCM (58). Eurythmy therapists usually work with their patients in a one-to-one setting and instruct them in exercises that can be performed at home. The therapy is designed for the individual person and is based on exercises associated with specific groups of symptoms. The connection with the organs heart, lung, liver and kidney is always considered because of the long-lasting impairment of essential organ functions after a COVID illness (59).

Short case history: In November 2020, a 23-year-old athletic male developed COVID-19 symptoms, tested positive and immediately went into quarantine. The symptoms were fever, dry cough, rhinorrhoea, myalgia, headache, sore throat, dyspnoea, asthenia, fatigue and general tension in the body. The fever lasted only 3 days, dry cough, rhinorrhoea, myalgia, asthenia and headache for 14 days. He did not suffer from any underlying diseases, which favoured a mild COVID-19 course. Besides paracodeine drops, paracetamol (one-time), honey and sage sore throat tablets, fennel and chamomile tea and a balanced healthy diet, the patient gave himself help with some of the eurythmy therapy exercises he had learned since July 2020: 7-part rod exercise (60), waterfall rod exercise (61), 12-part rod exercise (62) and lemniscates with the copper ball (63) performed in front of the torso. After the fever had subsided, he practised at least once a day and additionally as needed. The patient described the lemniscate movement with the copper ball as calming and relaxing overall, leading to an improvement in cough, headache and fatigue. He attributed the improvement in chest pain, dyspnoea and fatigue to the fact that the whole body was stretched and vitalised by the 7- and 12-part rod exercise. Beyond the acute condition, dyspnoea, fatigue and occasional impaired concentration as well as headaches persisted until May 2021. The patient himself actively put together an exercise programme and used it in situations when needed. Self-help exercises (SHE) can alleviate the emotional burden associated with COVID-19 (64) and symptoms of exhaustion (65). The patient's statements suggest that eurythmy therapy encourages self-activity and has a positive effect with post-COVID-19 symptoms.

The following exercises (66) have already proven effective in the treatment of long-lasting symptoms following an illness with COVID-19. The differentiated information on the exercises can be found in the basic works of Rudolf Steiner (67) and Margarete Kirchner-Bockholt (68), among others.

Download: Table symptoms overview

Artistic therapies, psychotherapy

Music and singing therapy as well as modelling and painting therapy as well as dynamic form drawing support the therapeutic principle of revitalising the senses, stimulating the etheric regenerative processes, and the artistic-creative act of turning to one's own emotional expressiveness and cultivating self-efficacy.

Breathing, singing and speech exercises are especially recommended for patients with a fibrosing course.

Talking therapy, biography work and/or meditation exercises are indicated in cases of emotional and spiritual distress.

Complex rehabilitation cures may be advisable – e.g. at the Casa di Salute Raphael in Roncegno/IT and at the Paracelsus Hospital in Unterlengenhardt/DE.

Due to the compromised immune system and weakened organ functions, relapse, recurrence and new infections are possible in post-COVID/post-vaccination patients. Hence prevention is important.

In the acute phase of COVID-19, the regulated course of fever should be positively supported (69).

From the first day of the acute phase of the illness, it is advisable to put aside daily obligations and set up media-free time for recovery. If there are clear symptoms of the disease, this period should comprise four weeks.

Lifestyle

Exercise in nature (70, 71), healthy nutrition with sufficient food breaks, regeneration times, sleep and media hygiene should be maintained and practised. Systemically, attention should also be paid to exhausting, that is preventing the exhaustion of resources in the family and, as relevant, professional environment.

Acknowledgements: We would like to thank the members of the Anthroposophic Medicine Forum (GAÄD) for their suggestions and sharing their experiences.

Conflict of interest: Harald Matthes is a member of the Administrative Board of Weleda AG.

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