Long COVID from the Perspective of Anthroposophic Medicine – Symptoms and Treatment Options

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 of the acute phase, they appear less frequently in PPCS. However, severe gastrointestinal motility disorders have been described.

The most common long-term neurological disorders (PCND) include: sleep disorder, dizziness, taste and smell disorders (14), polyneuropathy (CIP), ischaemia/apoplexy due to endothelitis and coagulopathy, autoinflammatory demyelination, encephalitis (15). The central nervous system seems to be affected more than the peripheral. The most common mental and psychological disorders include: memory disorders, impaired concentration, lack of presence of mind ("brain fog"), stress intolerance, anxiety (16) and depression, post-traumatic stress symptoms (PTSD) (17), obsessive-compulsive disorder (OCD), subjective distress and deterioration in quality of life (18, 19). Here, nocebo effects must also be taken into account, which can be attributed to pandemic measures such as social distancing (20, 21). Ten to 15 percent of those affected take psychoactive substances, ten percent have suicidal thoughts.

Pathophysiology

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

• Persistent inflammation (endothelitis, myositis, myocarditis (with elevated serum parameters: CRP, D-dimers, LDH)), increased thromboembolic events (22).
• 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 (23). Innervation disorders and weakened respiratory muscles may also contribute to complex respiratory insufficiency after COVID (24).

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

Endothelitis and disorders of the blood-brain barrier play an essential role in damage to the sensory and nervous system.

Diagnosis

An individualised medical history is required, which also includes the time before falling ill with COVID, and a complete physical examination, which is specifically supplemented by laboratory and functional diagnostics (pulmonological, cardiological, neurological). The change in quality of life can be evaluated by questionnaires (e.g. SF-36, E5-QD) or by Management of Daily Life questionnaires.
After the initial staging, regular follow-up examinations and a final examination are indicated.

Extended understanding of disease from the perspective of Anthroposophic Medicine

The dynamics of infectious diseases are determined by the interaction of the microorganism with the affected person, their susceptibility to the pathogen and their fabric of forces. COVID-19 in the first instance clearly shows the importance of age and biographical development. Genetic disorders (Down’s syndrome) can significantly reinforce the relevance of the ageing processes. The vitality of the body decreases with age and can be impeded by obesity, metabolic diseases such as diabetes mellitus and others. A significant role in post-COVID is played by disorders and dissociations in the patient's fabric of forces. These normally proceed in a dynamic equilibrium between a dissolving and hardening tendency (25). In contrast, chronic inflammation and a degenerative, hardening (sclerosing) tendency dominate and persist in Long COVID, which are experienced mentally as exhaustion and are accompanied by the weakening of generative vital processes.

The decisive factor is whether, especially at night, during sleep, the inflammatory degenerative tendency recedes in favor of vital generative processes. This day-night rhythm can be severely disrupted in Long COVID. From an anthroposophical perspective and therapeutic experience, the focus here is on strengthening of the warmth organisation ("I-organisation") in order to achieve the changeover from persistent inflammatory processes to a day-night rhythm with nightly predominant generative processes. Other, often younger patients suffer predominantly from a post-viral dissociation of their bodily vitality. This is where treatment primarily starts, to support the patients so that they can direct the organism again with the power of their individuality, perceive themselves, and deploy their vitality. In doing so, it is essential to revitalize the body itself and make it receptive to psychological impulses. It is 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.

A normally low level of effort proves exhausting for many. Even breathing loses its naturalness. Dyspnoea, fatigue are often accompanied by anxiety. Not infrequently, there are also cognitive impairments in the ability to think and concentrate and in memory retention. Some patients say that they experience something alien within them that feels different from other infectious diseases they have been through. They often 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 (26, 4, 27).

Drug therapy
Pharmacotherapy is based on the established spectrum and corresponds to the organic permanent injury to health or respective functional disorders.

Non-drug therapy
Cardiopulmonary rehabilitation measures, such as e.g. breathing techniques ("inhalatory muscle training") (28, 29), breathing exercisers (e.g. Tri-Ball system) should be used under professional physiotherapeutic supervision.  With incremental exertion, monitoring of heart rate and oxygen saturation may be indicated.

Psychological/psychotherapeutic, neuropsychological (such as e.g. olfactory training), neurological, psychiatric rehabilitation measures (cognitive training, etc.) may be indicated up to and also during reintegration/fitness for work (30).

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. Heat: The patients show a picture of the stagnation of inflammation and/or fibrosis. The therapeutic stimulation of body temperature (I-organisation) can enable the self-regulatory processes to intervene again on all levels. The patient's self-perception can be directly addressed through heat. At first, many patients do not consciously feel the inner lack of heat. By strengthening and supporting the warmth organisation through appropriate clothing, external applications, self-active treatment methods and anthroposophical medicines (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 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.

2. Respiration: The one-sided failure of respiration and life rhythms, which takes on a life of its own and which can be accompanied by typical anxieties, needs to be re-integrated and harmonised on a physical as well as on a psychological level. 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 emotionally and physically of stressors that take on a life of their own. Care and self-care, rhythmisation of everyday life with regular breaks, individually appropriate, moderately self-active and artistic treatment methods (see principles 5 and 6) can open up new access to the content of psychological experience.

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 stimulate body awareness via the skin, directly promote inner vitality and can improve sleep quality. A revitalisation of the microcirculation can be achieved through rhythmical massage therapy, the revitalisation of body awareness and deepening of the sleep-wake rhythm through rhythmical Einreibung. Actively, such revitalisation can be achieved through forest bathing (31, 32) and/or eurythmy therapy. Stabilising a healthy daily rhythm with adequate breaks is essential. The rhythm of meals contributes significantly to this. The diet should support vitality, with organically grown fruit and vegetables, regular freshly cooked hot meals and adequate food breaks. Bitters support vitality, promote generative processes and strengthen the interaction between soul and body. Lastly, anthroposophical medicines can 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 area of the lungs, cardiovascular system and kidneys, and functional organ disorders, such as "brain fog", can be treated complementarily with anthroposophical medicines and eurythmy therapy. 

5. Self-activity: A person's own limits must be carefully observed and can only be 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 also 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 Long COVID to have a four-week interval in which the focus is on therapy and reorientation and the workload is 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 speech therapy 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 loss of trust, the alienation from our own corporeality, it is essential to promote trust in our own corporeality through external treatments. Related to organs, heart compresses with Aurum/Lavandula comp. ointment, abdominal Einreibung with Oxalis oil, kidney compresses with ginger, and foot baths with lavender should for example be considered here (31). 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 for the future. Small first steps can be significant in the first instance here.  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. This enables the patient to 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 individualized goals. Spiritual and religious aspects can be of significance depending on the individual relationship with them.

1. Support of the warmth organisation – medicines 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 patients, thus strengthening the patient's self-regulation. 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) to vitalise the metabolic system,
• birch mistletoe (Betulae) for depressively tinged exhaustion and to vitalise the kidney/adrenal system,
• pine mistletoe (Pini) in disorders of the nervous and sensory system (33) .  

Preparations that can be considered for this are:

• ABNOBA Viscum Crataegi, Aceris, Betulae, Pini: 0.02mg 2 x/wk, after 8 amp., followed by 0.2mg s.c. 2 x/wk
• HELIXOR P Series Pack 1: 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. s.c. 2 x/wk Potency Series I, repeat if required  

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

• Aurum D 10/Ferrum sidereum D 10 amp. WELEDA: 1 – 3 x/wk s.c. or
• Aurum D12 trit. WELEDA: 1 saltsp. 1 – 2 x/d
• Ferrum sidereum D 20 tab. WELEDA: I tab. 1 – 2 x/d  

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

• Ferrum hydroxydatum 5% trituration WELEDA: 1 – 2 saltsp. 3 x/d, on failure
• Ferrum hydroxydatum 50% trituration, Apotheke an der WELEDA: 1 x ¼ - ½ level teaspoon in the morning.  

For conspicuous feelings of cold, circulatory insufficiency – quickly invigorating and warming effect

• Camphora D 1 WELEDA: 5 – 10 gtt in water 1 – 3 x/d
• Camphora D 3 amp. WALA: 1 amp. s.c. 3 x/wk – 1 x/d. 
  

2. Respiration

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

• Bryonia/Stannum amp. WALA: 1 amp. s.c./d (upper abdomen or between the shoulder blades)

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

• Roseneisen/Graphit pillules/amp. WALA: 1 amp. s.c. 3 x/wk/ 10 – 15 pillules 2 - 3 x daily.

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

• Verbascum comp. WELEDA: 3 x 20 gtt.

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

• Pulmo/Mercurius Amp. WALA : 1 amp. s.c. 3 x/wk.

3.  Cardiovascular system

For exhaustion, circulatory and blood pressure regulation disorders, tachyarrhythmias, possibly also sleep rhythm disorders

• Cardiodoron® Tr. 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.

Supplementary for myocarditis

• Cor/Aurum II Amp. WALA: 1 amp. s.c. 1 x/d – 2 x/wk.

For exhaustion, chronic persistent pain, post-viral burn-out syndrome

• Crataegus/Ferrum sidereum/Saccharum tostum Amp. WELEDA: 1 amp. s.c. 3 x/wk.

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

• Skorodit Kreislauf Globuli WALA: 10 pillules 2 – 3 x/d
• Skorodit Kreislauf Inject Amp. WALA: 1 amp. s.c. 3 x/wk – daily

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

• Kalium aceticum comp. D6 Amp., Verreibung WELEDA: 1 amp. s.c. 1 x/d 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).

5. Musculoskeletal system

For myalgias, muscle weakness

• Magnesium phosphoricum acidum D6 WELEDA: 50 gtt 1 x/d Take dissolved in water throughout the day
• Plantago Primula cum Hyoscyamo Amp. WELEDA: 1 amp. s.c. 2 – 3 x weekly or 1 amp. per os daily
• Primula Muskelnähröl WALA: apply locally

6. Sensory and nervous system

For loss of smell, disorders of the sense of smell

• Bulbus olfactorius D5 Amp. WALA: 1 amp. s.c. 3 – 7 x/wk. or per os
• Jaspis D6 – D12 Verreibung , z. B. Apotheke an der Weleda: 1 x 1 saltsp. Daily  

For loss of taste

• Topas D15 Amp. WALA, D12: (extemporaneous production) 1 amp. s.c. 3 x/wk or 10 gtt/pillules/1 saltsp trituration 1 x/d

For headache, weakness, possibly iron deficiency

• Ferrum/Quarz Kapseln WELEDA: 1 – 3 x/d, if required supplemented by
• Ferrum sidereum comp. Amp. WELEDA oder Ferrum/Sulfur comp. WALA: 1 x/d - 2 x/wk s.c. in the neck area

For "brain-fog", cognitive weakness and disorders (retentiveness, ability to concentrate)

• Scleron® Tbl. WELEDA: 1 tab 1 – 2 x /d
• Helleborus niger D12 Amp. WALA, HELIXOR : 1 amp. 1 – 3 x/wk.

7. Sleep disorders

For difficulties falling asleep and staying asleep

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

alternatively

• Calmedoron® Tr. WELEDA : 15 – 20 gtt 1 x/d in the evening

8. For vital weakness, depression and emotional irritability

• Aurum/Apis regina comp. Amp., Glob. WALA: 1 amp. s.c. 1 x/d – 2 x/wk; 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. s.c. 3 x/wk   

can be supplemented with

• Levico D1 Tropfen, WELEDA : daily. Gradually increase from initial dose (5 gtt) to target dose (20 gtt daily) and continue as long as needed.

Composition of the German medicinal products mentioned: 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. Skorodit Kreislauf Glob./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 pepper fruit (Piperis nigri fructus), sugar. Ferrum sidereum comp.: Ferrum sidereum Dil. D8, Quarz Dil. D20, Sulfur Dil. D6. Scleron: Plumbum mellitum Trit. D12 (Plumbum mellitum base substance: produced from plumb, honey and cane sugar). Calmedoron Tr.: Avena sativa Ø, Coffea tosta, ethanol. Decoctum Dil. D60, Humulus lupulus Ø, Passiflora incarnata, Valeriana, ethanol. Decoctum Ø .

Nursing measures, external treatments

Principle 1. Strengthening the warmth organisation

Heat treatments have a primary role as they promote the harmonising intervention of the warmth organisation, especially in patients with a fibrosing course, exhaustion with a feeling of cold.

• Warm footbaths (34) 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 instructions, see https://www.pflege-vademecum.de/ingwer.php?locale=en  
• Kidney Einreibung with Red Copper ointment (Kupfer Salbe rot) 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 instructions, see https://www.pflege-vademecum.de/odb-grl-oel.php?locale=en .

Principle 2. Harmonization of the breathing

• Yarrow lung compress for residual lung damage 1x/d for 5 consecutive days, then 1-3 x /wk, for instructions, see https://www.pflege-vademecum.de/sg-luw.php?locale=en
• 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 instructions, see https://www.pflege-vademecum.de/rosm-ku-zfw.php?locale=en  

Principle 3. Fluid and circulation

• Yarrow liver compress for weak vitality, to initiate treatment (if necessary Millefolium 10% ointment WELEDA CH) 1 x/d for 5 consecutive days, then 1-3 x/wk. Ffor instructions, see https://www.pflege-vademecum.de/schafgarben_leberwickel.php?locale=en  
• Rosemary-copper diaphragm compress, 1 x/d for 5 consecutive days, then 1-3 x/wk. For instructions, see https://www.pflege-vademecum.de/rosm-ku-zfw.php?locale=en

Principle 4. Regeneration of tissue disorders

• Thorax Einreibung with rock salt + 3 gtt rosemary oil for fibrosing lung changes 1 x/d for 5 consecutive days, then 1-3 x/wk
• To stimulate the metabolism in general: yarrow liver compress, 1 x/d for 5 consecutive days, then 1-3 x/wk., for instructions, see https://www.pflege-vademecum.de/schafgarben_leberwickel.php?locale=en

Principle 7. Psychosomatic complaints / pain

• To support embodiment in general: rosemary-copper diaphragm compress; 1 x/d for 5 consecutive days, then 1-3 x/wk., for instructions, see https://www.pflege-vademecum.de/rosm-ku-zfw.php?locale=en
• For post-traumatic symptoms: pentagram Einreibung with Aurum/Lavandula comp. ointment WELEDA for three consecutive days, for instructions, see https://www.pflege-vademecum.de/aurum_lavandula_salbe.php?locale=en
• Invigorating rhythmising effect: alternately rosemary footbath 1 x/d in the morning and lavender footbath 1 x/d in the evening.
• Head: spray Formica D1 WELEDA as a spray 1:5 or Arnica tincture 1:10 on the head, 2 – 3 sprays 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: Heart lobe or organ Einreibung with Aurum/Lavandula comp. cream WELEDA for impairment of mental functions, "brain fog", for functional heart complaints, anxiety.
• Abdomen: Oxalis upper abdomen compress/Einreibung after traumatic experiences;
  see also https://www.pflege-vademecum.de/oxalissalbe.php?locale=en .  
• Muscle/joint pain: Einreibung with Aconite Schmerzöl (Nerve Oil) WALA.
• Feeling of exhaustion: oil dispersion baths with prunus, rosemary.

Body therapy

Rhythmical massage therapy with Oxalis 10% oil WALA for anxiety (35),
Betula/Arnica oil WALA for pain and cramps,
Rosemary oil for exhaustion.

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.

It is a holistic, self-activating, movement-oriented mind-body therapy (MMBT) within Anthroposophical Medicine that uses movement exercises with arms, legs and the whole body (36) to harmonise dysfunctional functional, vital-emotional and intentional processes in the human organism (37) comparable to Traditional Chinese Medicine TCM (38). Eurythmy therapists usually work in an individual setting with their patients and give exercises that can be done at home. The therapy development focuses on the individual person and is based on exercises attributed to certain symptom circles. The connection with the organs, heart, lungs, liver and kidneys is always taken into consideration because of the long-lasting impairment of the essential organ functions after a COVID disease (39).

Short case history: In November 2020, a 23-year-old athletic male developed COVID-19 symptoms, tested positive and immediately went into quarantine. Symptoms included fever, dry cough, rhinorrhoea, myalgia, headache, sore throat, dyspnoea, asthenia, fatigue and general body tension. The fever lasted only 3 days, dry cough, rhinorrhoea, myalgia, asthenia and headache 14 days. He did not suffer from any underlying diseases, which favoured a mild course in COVID-19. Besides paracodeine drops, paracetamol (one time), honey sage throat pain tablets, fennel and chamomile tea and a balanced healthy diet, the patient helped himself with some of the Eurythmy Therapy exercises he had learnt since July 2020: 7-fold rod exercise (40), waterfall rod exercise (41), 12-fold rod exercise (42) and lemniscates with the copper ball (43) performed in front of the torso. After the fever had gone down, he practised daily at least once and additionally as needed. The patient described the lemniscate movement with the copper ball as overall calming and relaxing, resulting in improvement of 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 exercises. Beyond the acute condition, dyspnoea, fatigue and occasional concentration problems and headaches persisted until May 2021. The patient self-actively put together an exercise programme and practiced it in situations of need. Self-help exercise (SHE) can improve the emotional distress of COVID-19 circumstances (44) and symptoms of fatigue (45). The patient's information suggests the self-active nature and positive effect of eurythmy therapy for post-COVID-19 symptoms.

The following exercises (46) have already proven their worth in the treatment of long-lasting symptoms after an illness with COVID-19. The differentiated information on the exercises can be found in Rudolf Steiner's (47) and Margarete Kirchner-Bockholt's (48) basic works.

Table of symptoms and exercises (PDF)

Art Therapies, Talking Therapy

Music and singing therapy as well as painting therapy support the therapeutic principles 6 and 7.

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

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

Complex rehabilitation cures may be worth recommending — e.g. at the Casa di Salute Raphael in Roncegno.

Due to the compromised immune balance and weakened organ functions, a relapse, recurrence or new disease is possible in post and Long COVID patients. Hence prevention is important.
In the acute phase of COVID-19, the regulated course of the fever should be positively accompanied and supported (49).
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 and space for recovery.  If there are clear symptoms of the disease, this period should comprise four weeks.

Lifestyle

Exercise in nature (50, 51), healthy nutrition with sufficient food breaks, regeneration times, sleep, media hygiene should be maintained and practised. Systemically, attention should also be paid to exhausting resources in the family and, as relevant, professional environment and preventing this from happening.

Vaccinations    

Data to date show no significant worsening of Long COVID symptoms after administration of mRNA or adenovirus vector vaccines (52).
In individual cases, vaccination can even have a slightly positive effect on the improvement of symptoms (own observations). The risk factors and immunological parameters (incl. signs of immunosuppression, autoimmune tendency, inflammatory parameters, proinflammatory factors, SARS-Cov-2 IgM/IgG antibodies) should be considered individually in the vaccination decision (53).
Having had the disease provides natural immunity against further severe courses of the disease (54), its sustainability is still subject of further research. 

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

Conflict of interest statement: The authors declare no conflicts of interest.

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