Jill Brook: [00:00:00] Hello, fellow POTS patients, and marvelous people who care about POTS patients. I'm Jill Brook, your horizontal host, and today we are interviewing Dr. Robert Groysman, who has a clinic in Irving, Texas where he started treating long COVID patients and now also treats patients with POTS, MCAS, ME/CFS, and all those syndromes we talk about here. He is a diplomat of the American Board of Anesthesiology and American Board of Pain Medicine, and a proud member of the Texas Pain Society, American Society of Interventional Pain Physicians and Spine Intervention Society. He has authored books about managing and treating long COVID and dysautonomia, and he has been pioneering research and novel treatments including stellate ganglion block, epipharyngeal abrasive therapy, or EAT, nicotine patches, vagus nerve stimulation, and others.

And I know you are so excited to hear all about those therapies. Dr. Groysman, thank you so much for being here today.[00:01:00]

Dr. Robert Groysman: Thank you so much, Jill. Glad to be here.

Jill Brook: So maybe do you mind just starting by telling us a little bit more about your background and how you became interested in this area of complex stuff?

Dr. Robert Groysman: Sure. So, long COVID kind of fell in my lap. I was treating a condition called PTSD, Post-Traumatic Stress Disorder back in 2019 and 2020, and we started seeing some patients coming in with loss of smell or taste and abnormal taste and smell. And we noticed that after I performed the stellate ganglion block procedure, their smell and taste came back.

Now, at the time, we didn't really know what long COVID was. It didn't really have a name until a few months later. But that was my first interest in what is going on here. As soon as we learned about what long COVID was, it was a postviral syndrome [00:02:00] happening after recovery from SARS CoV-2 or COVID-19 virus, I started looking into it. It became an interest of mine and it turned into a passion, and I started doing a lot of research. I borrowed a lot of papers from chronic fatigue syndrome or CFS/ME and dysautonomia papers and vagus nerve stimulation, and started incorporating this into my treatments. So that's pretty much my origin story for, for how I got into it.

Jill Brook: And I guess it's just coincidental that you already had all this expertise in pain because there's so many different kinds of pain in dysautonomia and long COVID. Everything from nerve pain to stomach aches and headaches and, and you just coincidentally already had all that expertise.

Dr. Robert Groysman: Yes, I, I did. And plus I added a lot of additional expertise from the other mechanisms that I found to be [00:03:00] associated with long COVID and also with CFS/ME.

Jill Brook: Ah, so one thing I noticed about your website that I liked is you talk a lot about mechanisms and you share a lot of great information and you have a quiz where people can talk about their symptoms and you give them some feedback on what might be contributing. And it kind of looks like you figured out that long COVID was made out of a cluster of different issues that a lot of us already had even before COVID came along.

And so I feel like even though your expertise maybe like started out in the long COVID space, are you noticing that you're like getting a lot of people like me, for example, who have all the same issues, but we had it since before COVID?

Dr. Robert Groysman: Yes, I see, I see a lot of patients and people I talk with who are basically alongside long COVID. They may have had preexisting conditions, including POTS, including dysautonomia, including chronic fatigue syndrome, and so forth. And I'm [00:04:00] finding that what I'm doing for long COVID also works for these other conditions.

To a lot of people's surprise because you know, people have been having chronic fatigue syndrome for 20, 30, 40 years, and there's usually very specific kind of treatments that are given for it, but it doesn't really get rid of chronic fatigue syndrome. So, some of the things that I've been doing have shown I guess increased responses even in people who have had it for many years.

So the mechanisms that I'm discovering in long COVID are applicable to other conditions as well.

Jill Brook: That is so exciting. So I would love to just shut up and let you talk about mechanisms.

Dr. Robert Groysman: Well, it obviously all started with dysautonomia. Since that, that's what I was treating for PTSD with this stellate ganglion block procedure.

Jill Brook: And I don't think our audience necessarily knows what that is.

Dr. Robert Groysman: So a stellate ganglion block procedure [00:05:00] in pain management is used for sympathetically caused pain, such as loss of a limb, for instance, like stump pain, as an example, or CRPS. Those are something that we use stellate ganglion block procedures for. However, there's been some interesting developments that shows that it works for other things that are caused by sympathetic overdrive.

And one of the uses for, for this procedure is PTSD. And the other is the, the correcting, the dysautonomia imbalance that long COVID causes.

Jill Brook: Oh, so the sympathetic overdrive that might lead to things like the shakiness or the bad digestion or the heart palpitations, like that kind of stuff, or what are you talking about?

Dr. Robert Groysman: Yes, exactly. So, I, I split up dysautonomia into kind of three categories. The first one is the fight or flight, which kind of everybody knows about, they, they start to [00:06:00] sweat, their pupils dilate, they breathe fast, their heartbeat goes up. So that's something that's a survival mechanism. That's great for survival, not so great 24 7.

One of the things that we see with consistent or constant fight or flight is anxiety that's not specific to anything, to anything that's going on in your life. You're just anxious. There's also problems with unrefreshed sleep, okay. So people spend a lot of time sleeping. They're unconscious, but they wake up and they feel like they did before they went to sleep.

That's all fight or flight. And yes, the palpitations, the tachycardia, all that support of the fight or flight. And all your senses are heightened, hearing, taste, smell, sometimes to an extreme that it bothers people, light. It's too much, even though, even though it's okay for everybody else.

So that's, that's all the fight or [00:07:00] flight stuff. There's, there's obviously more, more symptoms with it. And then you have the POTS, which is mainly gonna be orthostatic. So you stand up, you have the tachycardia, you feel dizzy or you pass out. And obviously there's a lot of other symptoms associated with POTS.

I'm just trying to be very general and, and short. And, and lastly is the vagus nerve dysfunction. Okay. And, and that involves the parasympathetic nervous system. So that's the other side of the coin. So all those three things are under the umbrella of dysautonomia and the stellate ganglion block helps with the sympathetic, the, the overactive sympathetic.

And I know we'll get into the EAT procedure at at some point, but that helps with the parasympathetic. So they kind of work synergistically.

Jill Brook: Okay, so, so yeah, we talk about that all the time, about how in dysautonomia you're out of balance with too much of the sympathetic i.e. fight or [00:08:00] flight and not enough of the parasympathetic i.e., rest and digest. And so you're saying you've got two things that can help people get back in balance.

Dr. Robert Groysman: Well, three things. We also do vagus nerve stimulation, and that's something people can do at home. Now when I'm talking about vagus nerve stimulation, I am talking about actually electrically stimulating the vagus nerve, not something that taps you or buzzes or massages you. You really have to electrically stimulate the nerve in order for it to get activity.

Jill Brook: So not just the thing that clips on your ear?

Dr. Robert Groysman: No, that's the one I use. But if you clip it on your earlobe, you're not gonna get anything. That's actually used as a placebo, in most studies for vagus nerve stimulation. They'll put it on the earlobe. The vagus nerve does not get any input from the ear lobe. You have to go into this inside area. Okay. I usually recommend the tragus which is this kinda outpocketing in front of the ear because it's easy to put a clip there and it's more difficult to put it in the concha [00:09:00] region here. But really any of this area here is fine. If you put it on here, it's not gonna do much. If you put it here, it's not gonna do much.

But vagus nerve stimulation is very useful and it works. So those are the three things that I recommend for, for dysautonomia.

Jill Brook: Wow. And so do you want to talk now or later about what a stellate ganglion block actually is like as far as a treatment goes? Like, I, I don't even know really what those words mean. Like what are you blocking and how?

Dr. Robert Groysman: So, the procedure is an advanced block, so it does require some skill to perform. There are some pain doctors that do it with x-ray guidance. It's called fluoroscopic guidance, which is a C-arm and it's live x-ray. I prefer to do it with ultrasound guidance, also live. And the reason is, is because ultrasound picks up all of the soft tissue.

And in this little space that we're going into we're talking about like, inch and a half by inch and a half cube [00:10:00] of space. You have the carotid artery, you have the vertebral artery. Both of those go to the brain. You also have your brachial plexus, which are the nerves that come out of your spinal cord.

And you have several other blood vessels. You have a thyroid gland. You have basically a lot of important structures in a very small area. Carotid artery, jugular vein. I, I mean, all these things are visible on ultrasound. They're not visible at all on x-ray, so, it's more like by landmarks. So I prefer to do it with ultrasound.

So the procedure is very easy to tolerate. I've done it in eight year olds awake. I do a two level block one at C6. You know, you have vertebrae that go from C0 to C7 in your neck, and C6 is really the [00:11:00] safest place to go. Sometimes we go a little lower, but the, the point is, is to get it to surround where the stellate ganglion lives.

Stellate ganglion is basically a relay, okay? It's a sympathetic nervous system relay and all the signals that come from the brainstem and the brain, also from the body, kind of relaying the station first before moving on. It's, it's sort of like, a communication center before the signal goes on somewhere else.

It helps coordinate what your heart rate does, your, your breathing rate, your bronchial size. Basically all these things are coordinated by the stellate ganglion. And when we basically numb it up, and that's all it is, it's just a local aesthetic, when we numb it up, it stops these signals from going on one side temporarily.

Now in cases of PTSD, for instance, the signals are being driven [00:12:00] by the amygdala, which is an area in the brain that's in the temporal region. That's where you store memories. But amygdala is kind of cool because it stores emotional memories. And if it's overdriven, it will continually stimulate the signals through the, through the stellate ganglion.

In long COVID, it's a little different. That's not where the signal is coming from. It's due to damage to the vagus nerve and the two centers in the, in the brainstem that get the signals from the vagus nerve. So that forces the sympathetic to work harder, be a higher tone, and that also causes your immune system to get all excited because not just your nervous system gets all excited, it makes your immune system excited too. And that can dysregulate it. So now you have things like inflammation, right? Fevers. All these things come from the sympathetic nervous [00:13:00] system. Because normally your parasympathetic will keep your immune system nice and quiet and basically moderated. But if you remove that break, all of a sudden your immune system goes a little haywire.

So all this is connected. But from the block standpoint it takes about five minutes to complete. And it's not, like I said, it's not uncomfortable. I've done young, young adults, teenagers, and elderly and really no issues.

Jill Brook: And what does a patient feel? Like, do they feel noticeably more calm or...?

Dr. Robert Groysman: So once the procedure is done, if we got the dominant side, so just like you have left handers and right handers, you didn't pick it, your body picked it for you. Your body also picks which side it prefers, the right or the left, even though we have both. And yeah, so about 80% of people tend to be right dominant.

Nothing to do with if you're right-handed or [00:14:00] left-handed. It's, you know, somewhat random. And 10% are left-sided and 10% are non-dominant, which means you need to block both sides in order, not at the same time, but you need to block both in order to get the benefit.

Jill Brook: Wow, interesting. Okay, and and so then, so what do people notice and how long does it last?

Dr. Robert Groysman: So most blocks that we do in pain, once the block wears off, you know, the, the benefit wears off for the most part. Of course, for pain blocks we use a little bit of a steroid to reduce the inflammation, but here, there's no inflammation. It's just a communication problem, a neural, a neural communication problem.

So this one is a little unique. When you stop the communication on the dominant side, if you have a dominant side, most patients will have like an emotional release, usually crying. Could be anywhere from five to [00:15:00] 15 minutes. It's completely nothing to do with pain or, or discomfort or anything else.

It, it's just kind of opening up that sieve of emotion, let it flow out. People say that they feel a weight lifted off their chest or their shoulders, they can finally breathe, like they can take a deep breath and actually feel it. Anxiety significantly released. Usually patients feel, have a really good night's sleep that night.

And that's part of it because when you're in fight or flight constantly or chronically, you don't get deep sleep. I don't know if that makes sense, but stage three sleep is what we're talking about. Not how deep you think you're sleeping, but actually if we put EEG on you stage three sleep is delta sleep.

And because you're in fight flight, your body is wired right now for survival. And you know, if you think about it from an [00:16:00] animal standpoint, if an animal is just sitting there deep asleep and something tries to attack you, they won't be able to wake up fast enough to run away or fight. So your body's doing the same thing.

It's not, it's basically saying, I'm not gonna let you get into deep sleep because you are in danger even though you're not, but your body thinks it is. So there is a, a cumulative counter for deep sleep. You need a certain amount every single day. If you miss it, your body doesn't say, oh well, I'll just make, you know, it has to make it up the next day.

So if you haven't had deep sleep for many nights, right, you're gonna be sleeping for 18 hours or longer for a couple of days, maybe even a week or two. You need to make up that deep sleep. And once your, once your body's able to deep sleep, it's gonna take full advantage of it. You're gonna feel so much better the next day.

It is probably the best night's sleep you ever [00:17:00] had, lemme put it that way.

Jill Brook: Wow. Sounds amazing. Wow. Okay. And so, so it sounds like it just takes away the fight or flight angle of the dysautonomia.

Dr. Robert Groysman: Yes.

Jill Brook: If I'm understanding you correctly, the the fight or flight might be addressed, but maybe not the other two parts that you were talking about. You said the orthostatics and then...

Dr. Robert Groysman: Vagus nerve dysfunction. It does help with POTS too. It helps with POTS too. POTS is sympathetic in nature, it's just a dysregulated, sympathetic system. Sometimes it runs hot, sometimes it runs cold. That's, that's why, plus it's delayed, delayed responses. So, I do see a lot of improvement from patients with POTS.

In many of my patients, their POTS goes away. So it doesn't directly address vagus nerve dysfunction, but if you know that vagus nerve or parasympathetic and sympathetic sit on the [00:18:00] opposite sides of a seesaw, when one goes up, the other one has to go down. So they're, they're always connected in some way.

So when you stimulate the vagus, you're making the sympathetic lower. And when you decrease sympathetic overdrive, you're making the vagus higher. So it, it's kind of two sides of the same coin.

Jill Brook: So would you ever have people do the stellate ganglion block and then also do vagal nerve stimulation? Or would you generally have people only do one or the other at any given time point?

Dr. Robert Groysman: No, I love vagus nerve stimulation, especially on the ear. I have patients do it before, I have 'em do it right after. In fact, I prefer they do it right after. I think that that's what stabilizes the sympathetic nervous system. So if you don't do the vagus nerve, it's in flux. So once you've corrected it, it's still very fragile and a little bit of stress here can send you back into sympathetic [00:19:00] overdrive or fight or flight. So if a person can do vagus nerve stimulation every day and do it consistently, they will help strengthen their autonomic nervous system and there'll be more resistant to kind of falling back into fight or flight. So you asked how long, how long does it last?

Well, it's variable. I mean, I have people who haven't seen back in four to five years. Now, some people come in once or twice a year for a touch up. They had a fight with their spouse or a kid or so or something at their job, and it set them slightly back. They kind of regressed, so they wanna kind of get back to where they were.

So they'll, they'll come in to get a touch up, but for the most part, if you do things right, you probably won't need to do it again.

Jill Brook: Wow.

Dr. Robert Groysman: Of course life is life and it's unpredictable and you [00:20:00] never know. Anesthesia or surgery can sometimes set you back. It's kind of a physical stressor.

Jill Brook: Yeah, so can you talk about that? So like what are the risks and who are good or bad candidates for stellate ganglion block?

Dr. Robert Groysman: So from my standpoint, when I select patients, I look for those who have dysautonomia triggers. Now, I know we haven't talked about mechanisms yet, but the way I determine what's going on is by their triggers. And the big ones for dysautonomia are gonna be symptoms that get worse with standing. So let's talk, let's talk about what kind of symptoms.

Well, tachycardia or palpitations or their brain fog gets worse or they become dizzy. All of those would tell me, yeah, dysautonomia is part of this. Hot room, okay, if you had taken a hot shower or, or in a hot room and your symptoms get worse, again, it points to [00:21:00] dysautonomia. And lastly is emotional stress. If you are under stress and your symptoms are getting worse, that really points towards the dysautonomia.

So I've identified somebody who either has POTS or dysautonomia, or both. That's first. So, the only thing that prevents me from doing the procedure is if you're missing a large chunk of your neck. In other words, you had cancer or something else, or some kind of trauma, and there's no anatomy left.

So there's no way for me to find where I need to go. That's number one. Number two is somebody who's on blood thinners. And I just told you, even though I can see all the major blood vessels like the carotid and the vertebral artery and the inferior thyroidal artery and there's many others, you still can't always guarantee that you're not gonna hit a small something.

So if you're on a blood thinner or a platelet inhibitor it's probably best to get off if you [00:22:00] can. So really, those two are the only things that would prevent me from doing the procedure on somebody. The last thing would be somebody who's too mature or too young and they're just not capable. But like I said, I've, I've, I've done 'em even in eight year olds without a problem.

Jill Brook: Wow, that's really something. So, okay, so I'm excited to talk about more of your novel treatments, but you did bring up this idea of mechanisms and how you really like to think about that first with people.

Do you wanna kind of talk about that and let that lead us to some of your other novel treatments that you're using?

Dr. Robert Groysman: Sure. So when I started, as I said, I, I was only looking at dysautonomia. Nothing else was really available. And then more studies started coming in, and I included mitochondrial dysfunction. Now, mitochondria, everybody knows from, you know, fifth to fourth grade that they're the energy, the powerhouses of the cell.

So they, they [00:23:00] make, they make ATP, which is our energy currency in our body. So anytime a cell wants to do anything, it needs to pay ATP. And COVID, the virus itself damages the mitochondria. Now that happens as part of its reproductive cycle. Now a lot of, a lot of viruses do this too, like the flu.

They'll utilize or use mitochondria as part of their reproductive cycle. But you notice that after the flu, after about two weeks of, you know, after you get over the flu, you feel pretty much the same. Most people don't have a postviral syndrome. So COVID must do something different, right, to the mitochondria.

Now we know the mitochondria are damaged, okay? This has been shown experimentally in the lab from patients who have long COVID. There's damage to the mitochondria. The damage comes from basically changing the membrane [00:24:00] potential or increasing oxidative stress, but they don't work right. These mitochondria don't work right. So what's different in long COVID compared to after the flu? Well, COVID has another little trick. SARS CoV-2 has another little trick that it does. It damages the repair mechanisms, basically the mitophagy or the autophagy of cells. So you can't clear out these damaged mitochondria and put new ones in.

So that, that's part of the process of long COVID. So, which organs are involved? Well, everybody's gonna be different. You're not gonna have damaged mitochondria in every single organ, and you're not gonna have damaged mitochondria a hundred percent in the entire organ. So look at the heart, the brain, the pancreas, the liver.

A small area is gonna be affected, but that's enough to cause a dysfunction. So mitochondrial dysfunction is is a secondary mechanism, okay, it's the second mechanism, I should [00:25:00] say. Third one is gut dysbiosis and leaky gut, okay. Again, COVID comes in, it damages the flora, okay. It likes to target the butyrate producing species, okay. We need butyrate in order to stabilize our colon, that basically the membrane, and we need butyrate to quiet down the the microglia in your brain, and microglia are basically your immune system in the brain. It's kind of its own police force. If you don't have butyrate, you will have some inflammation in your head or your brain.

So those are the two mechanisms that COVID itself causes by coming in and basically disrupting the, the gut flora. And when you disrupt the gut flora, you also get leaky gut, which means things that are supposed to stay in the gut, in the lumen of the gut, make their way out of the gut and into other areas where [00:26:00] they don't belong.

So that's that's number number three. Number four is gonna be mast cell activation and histamine tolerance. Okay, now this is a secondary mechanism, again, from dysautonomia making the immune system all excited. So your mast cells tend to discharge more than they should, and the histamine intolerance comes from there's, there's several different mechanisms for that, but the point is, is you can develop histamine intolerance separately from mast cell activation. Next you have endothelial dysfunction. Now we're talking about blood vessels here. Now, in the beginning, during COVID and early long COVID, it targets the large vessels.

That's why people have heart attacks and strokes. They'll have DVTs, they'll have other problems with vascular clotting, right? But later on, it's not so much. Later on during long COVID, it's targeting the small blood vessels [00:27:00] like the capillaries. Okay? And you, those clots are a little bit different. They don't cause heart attacks and strokes, but they can cause pain in different areas, including your heart, for instance. If the surface of your heart is deprived of those little blood vessels oxygen and blood flow, you can have chest pain that looks like like a heart problem, but it's doesn't, it doesn't really act like a heart problem.

Jill Brook: Is this the micro clotting problem that we hear about?

Dr. Robert Groysman: Yes. So, so it'll target mainly things like your fingers and toes.

But if you have it here, you're gonna have it everywhere else. You're gonna have it in your brain, you're gonna have it in your heart, you're gonna have it in other organs. So the, the next mechanism is hormone imbalance. And what I'm talking about here is your thyroid.

What I'm talking about is cortisol, which again, is related to dysautonomia, testosterone and estrogen. Okay, there's other hormones that are affected as well, but it's also kind of a secondary [00:28:00] mechanism because you need mitochondria to be able to generate or create these substances. In fact, steroids, sex steroids, testosterone, estrogen, they're made inside mitochondria, in specific cells in, in, in the, in the, in the body. But you can kind of see how they're all related. So I started off with, with one and started slowly expanding. Now there's other mechanisms, okay, but I only consider six. And the reason I only consider six is because these are the six that I found that have a causality.

That is, what I'm finding is causing the problem in long COVID. There's other conditions or other mechanisms like autoimmunity, for instance, that hasn't been proven yet as, as a causality. It's so far more linked to correlation. We find these things in long COVID patients, but we haven't been able to prove yet that it can cause. [00:29:00] Nevertheless there are some treatments for that as well, but I'm, I'm really looking at the, at the, those six main ones that I mentioned.

Jill Brook: Wow, it's so much. I mean, do you tend to see all six in every patient or do you tend to see just like one or two in most patients and the unlucky people might have like four or five or six or like what do you see?

Dr. Robert Groysman: So I've been doing this for for more than five years. And what I've discovered is that most people are, are gonna have more than one mechanism. Yes, there are some that have all six, but most will have two to three. And by diagnosing these mechanisms that are involved first and then targeting treatment to each of these mechanisms is how we resolve long COVID.

I'm not saying about a cure, okay, I'm not claiming a cure or anything. I am, I'm claiming remission, recovery. I mean you're feeling better. It doesn't mean it's forever. But you can go on with your [00:30:00] life. That's, that's really the whole goal of this, is to create a systematic plan based on the mechanisms that I'm treating. Not guessing, okay. I'm not picking supplements from a roulette wheel spinning it and then deciding, well, let's try this, let's try that. I'm diagnosing what's going on, and I'm treating what's going on. That's, that's really it. It's that simple. And it works also for other conditions because of this method.

Jill Brook: So, so what is the most common mechanism that you see, and what do you do about it outside of the, the dysautonomia and the stellate ganglion block?

Dr. Robert Groysman: So the top two mechanisms I see almost everybody have is gonna be dysautonomia and mitochondrial dysfunction. Those are the top two. Now each person is gonna have a main primary. It may be gut for one person, it may be endothelial for another, and then they'll have some contributory mechanisms that are supporting [00:31:00] the primary.

Jill Brook: Okay, so, so I know a lot of people, at least in my world, there's a bit of a buzz around EAT that you're doing. Can you talk about your EAT therapy and what is that and how does it work and why do you do it?

Dr. Robert Groysman: Sure. So it's it's a relatively old procedure. It's was started and invented in Japan in in the late 1960s. And in Japan they use it for what's called chronic epipharyngitis. Now I don't know if you ever opened up an anatomy book, but you won't find an epipharynx in there because it doesn't exist.

What we're really talking about is the combination between the nasopharynx, which is the area behind your nose, and I'm gonna show you here in a second my model, and oropharynx, which is the back of the mouth. Okay? Now, in that area, there's some lymphatic tissue, similar to lymph nodes, but it's more [00:32:00] similar to the tonsils you have.

You have these palatine tonsils that are on either side of your throat, but there's also para tonsils in your nose. They're called adenoids, or pharyngeal tonsils. Now, between the mucus and the inflammation and the stuff inside the lymphatic tissue, okay, there's a lot of remnants that kind of get trapped in there.

Now people just say, well, I'll just do a Neti pot. Well, a Neti pot is not gonna reach that area, okay. Neti pot is great for clearing out your sinuses, okay? But it's not gonna do anything for the back of your nose and throat. Okay, it's actually a lot deeper than people think. And it's not this way. It's straight back, like, like here. So we're talking about going straight back, and I, I know I can't really control this part, but we're talking about this tissue here, okay? [00:33:00]

Jill Brook: So, basically just di straight back from the nostril.

Dr. Robert Groysman: Yes. So your vocal cords are gonna be here, okay? This is the soft palate here. Tongue.

Jill Brook: Okay.

Dr. Robert Groysman: So it's about guiding a flexible camera.

Jill Brook: So you literally go up the nostrils with the flexible camera?

Dr. Robert Groysman: Yes. So yeah, so I guide it in to, to to, to this lymphoid tissue here. Okay.

Jill Brook: Just looks like the back of the throat.

Dr. Robert Groysman: Yes, it is the back of the throat. You're right. So I put a, I put a tiny, a very thin, smaller than a pencil. And it's flexible. It's smaller than your charging cord, which, which boggles my mind because I have no idea how they fit all that stuff in there and, and make it look good.

And an LED for light. But, and it also has a heater in there, so, it doesn't fog up because if you, you know what happens when you put a lens in, in hot breath, right? It's gonna fog up. So it heats up [00:34:00] the lens. Again, I have no idea how they do this.

Jill Brook: An expensive camera is what I'm hearing.

Dr. Robert Groysman: Expensive. Yeah. But the point is, is the camera just lets me see where I am.

And then I use a, a very thin metal nasal swab. But it's not a wood one where it's stiff. Mine is more flexible. And what I'm doing there is I'm rubbing the entire back of the throat and nose area. Okay, the nasopharynx. And the rubbing part is what does the work.

Now, of course, adding the zinc and other things can help, but really the, the main part that does the work is the rubbing. And if you don't see it, you can't get the entire area, you know, basically rubbed. So it needs to be visualized and that whole area needs to be basically rubbed back and forth. Okay, now we do numb it up. If you don't numb it up, it, it, it can make a [00:35:00] gag or it's very uncomfortable. But we do numb it up with a special atomizer, kind of like the ones that are used for perfumes back in the day. But this one goes in the nose and we use a very concentrated form of local anesthetics so that it numbs the entire area.

So it's, it's not the most comfortable thing, but it's also not uncomfortable either. And it takes a few minutes to do, basically go through the thing, and basically the entire nasopharynx. And what I do is I record four different metrics, okay. I record bleeding. Is there, is there bleeding?

And again, all of these are zero to two. Swelling. How much swelling there is, how much mucus there is. Okay? And lastly is how much redness. So all those, and the score is zero to eight. And this helps me track later on because these are repetitive. So, with EAT procedures, if you want to get a good result, you need to do them repeatedly, at least a week [00:36:00] apart. I can do 'em more frequently together, but it's gonna be more uncomfortable. And as we do them you start seeing things like head pressure or, or, or brain pressure or ear fullness or tinnitus. Throat issues, voice changes. Some people come in, they have dysphonia.

They have either a hoarseness or a change in their voice. I, I treated a singer. It makes a difference.

Jill Brook: Wait, all these things are getting worse or they're getting better.

Dr. Robert Groysman: They're getting better. They're getting better. That's why we're doing the EAT. We're doing the EAT. So while I'm in there, it's kind of a unique area, okay? I'm stimulating three different nerves, all cranial nerves, okay? We're stimulating the vagus nerve in a very unique way, not in any way you can do with the ear.

We're stimulating the trigeminal nerve, okay? Pain in the face, pain in the sinuses, all that is connected. And lastly, the glossopharyngeal nerve. And these are all [00:37:00] cranial nerves that are involved with your autonomic nervous system.

Jill Brook: Oh, okay, so, so what other benefits do people tend to see and how long does it last?

Dr. Robert Groysman: So the lasting part is the repetitive nature, okay? As you do them more often, you can split 'em or separate 'em more apart because you don't need 'em as much. So, maybe the first time a week or two, maybe longer, I don't know. If you plan to just do one, then don't bother. Seriously, don't bother because you're wasting your time.

If you're gonna commit to this, you have to do several. I, I can't tell you exactly how many to do, but people get anywhere from four to eight, sometimes more.

Jill Brook: Okay.

Dr. Robert Groysman: Depending on how they feel afterwards. But it helps with postnasal drip, it helps with sinus pressure. So basically all this stuff is being driven by a low level chronic inflammation in the nasopharynx.

Okay? It's sitting in, in, in layers of mucus in biofilm [00:38:00] inside or on top of the lymphoid tissue. Not just, not just little remnants, okay? I'm talking about pieces of viruses, bacteria, fungus, I mean, you name it, it's in there. You know, it's like that, that tomato sauce commercial, right? It's in there. There's also inflammatory mediators.

Okay? You have interleukins, you have cytokines. They're all stuck in there. And this area is what produces IgA right? That's what protects you from stuff that you're breathing in and eating. So. If you have a lot of inflammation, you're not really gonna have a lot of IgA production, so you're more susceptible to infections and stuff.

Jill Brook: Oh, now you said they do this in Japan.

Dr. Robert Groysman: Yes.

Jill Brook: And it started there for a different purpose.

Dr. Robert Groysman: Yes. But there was a Japanese scientist who ended up treating some long COVID patients and saw a huge improvement and they went even further. They looked [00:39:00] at interleukins and inflammatory markers between the two sessions, basically before and after. So these are clinical lab results that, that show that it's actually removing the inflammatory mediators. And you can actually see the difference. Basically, if you look in before and after, the, the quality of the tissue changes, the texture changes. You start seeing blood vessels again. If you look in somebody who's really inflamed, you won't see anything. It, it looks like like cotton, like a texture of cotton.

And as you work on it, it starts to slowly change.

Jill Brook: Oh, interesting.

Dr. Robert Groysman: One of the things that they discovered in Japan is that this low level chronic inflammation, well, that inflammation carries over and this is driving some of the inflammation going on in the brain too.

So headaches, pressure, all that [00:40:00] stuff that people are feeling. Nothing is helping, right? They, they've tried a bunch of different things, including medications, including supplements, including even pain relievers.

And that pressure, that inside pressure that's pushing out, it's not going away.

Jill Brook: Does this ever help brain fog?

Dr. Robert Groysman: Yes, it would be part of, that's why I use 'em together. So brain fog primarily is mitochondrial, but remember what I told you about mechanisms. There's also endothelial dysfunction there, and there's also dysautonomia in there, and I just told you that if you don't have the butyrate being made in your gut, that's also gonna cause inflammation and, and problems in your head.

In fact, there was a study in Japan, again, I believe it was Japan, but it may have been China, where they looked at a specific probiotic and it was helping with brain fog. So here's just a gut mechanism, okay? We're not even talking about dysautonomia or mitochondria, we're just talking about [00:41:00] gut mechanism.

That's why you can't ignore any of 'em. You really have to consider all six.

Jill Brook: Right, right. Okay, so, so your website also mentioned another treatment that I'm really interested in, which is nicotine patches. And, you know, you hear this, you know, here and there and it's of course very controversial. But I know that you are very dedicated to evidence-based stuff, and so I was just curious to hear what you had to say about it.

Dr. Robert Groysman: So I, I'm, I'm glad you brought this up. I don't really recommend nicotine patches as much anymore as, as I used to. And that has to do with the evidence that that I've reviewed. So, couple things. Number one nicotine does not bind to ACE2 receptors. Okay, but nicotine can increase the number of ACE2 receptors on cells.

It acts like a transcription factor. It gets inside the cell, it gets inside the nucleus, and it basically makes the cell produce more [00:42:00] ACE2 receptors. Now, why is that important? Because when you have the COVID virus inside you, it enters through ACE2 receptor. Now the spike protein binds to the ACE2 receptor, and the whole thing gets sucked into the cell.

It gets engulfed. And the ACE2 receptor does not return back to the cell surface, see, so if you do this enough times, you don't have any ACE2 receptors. Now that's more important for hemostasis or basically blood pressure control and things like that. Okay, nicotine does bind to the A7 nicotinic ACh receptor, okay?

That is what is responsible for the cholinergic anti-inflammatory pathway. Okay, so that's how it acts through basically decreasing inflammation. However I'm gonna say it here, it does not displace spike protein from those receptors. [00:43:00] And the reason is, and there's proof of this. The reason is, is they bind to different sites on the receptor.

So it's kind of like, if you have a car and you have four passengers, well, if you want to get rid of the driver, you need to go into the driver's door. If you go into the passenger door, you're not gonna make the driver leave, see. So the same thing happens here. The, the spike protein binds to one area of the receptor and the, the nicotine would bind to another.

Jill Brook: Okay.

Dr. Robert Groysman: Okay? So it doesn't get rid of the spike protein. It doesn't remove it. So it was a nice idea, but that's been kind of disproven at this point.

Jill Brook: Okay. No, well, I appreciated you're exploring all these novel things and, and looking into 'em. That's fantastic.

Dr. Robert Groysman: So the, the most useful part of nicotine would be the activation of the cholinergic anti-inflammatory pathway, but just using it for that doesn't make sense. I, I guess you can use it for a few days to replace [00:44:00] the ACE2 receptors, if that is potentially a mechanism, but it doesn't require, you know, months and years of nicotine patch use.

Knowing that and knowing that it can potentially damage endothelium long term, I have kind of pulled back on it or if I'm gonna use it, you saw, I changed on my website to basically two weeks, to four weeks max. Again, I'm trying to prevent harm.

Jill Brook: Sure. So given that you mentioned endothelium again, what are the symptoms you see in people who are predominantly injured in their endothelium?

Dr. Robert Groysman: So endothelium is one of those mechanisms that doesn't have super specific symptoms that you'd be able to tell it's endothelium. So one thing you can, you can look at is a rash called livedo reticularis. Now it kind of looks like a lacy rash. It's red, and you'll have normal skin [00:45:00] in between the the lace.

Another thing you can look for are changes in color in fingers and toes in particular. So, things like, you know, the COVID toe or having your fingers turned blue or red or, or purple could be suggestive. But if, if you really look at from symptoms standpoint only, you can't tell it's endothelium.

So I actually do a test in the office it's called nailfold capillaroscopy. And what this is, is I'm looking at the junction between the nail and where your nail fold starts, and I'm magnifying it significantly, over 200 times. And what I'm looking for is the integrity of the capillaries. And if there's damage to the capillaries here, if there's missing capillaries, in other words, you look there and it's barren field, that pretty much gives you a clue something is up with endothelium.

Jill Brook: Okay.

Dr. Robert Groysman: If that looks normal, I, I don't really [00:46:00] pursue it as much. But if you see it here, you're gonna see it in the brain. You're gonna see it in the heart, you're gonna see it in all the other organs. You just can't take a peek inside the brain or the heart or other organs.

So this is kind of an easy place to look. Looking at it is not the, the hard part. Basically deciphering what it means is. So, that's how I typically diagnose endothelial or micro clot issues, is by looking at the nail fold and seeing if there's damage there.

Jill Brook: And so we've been hearing from some some of the long COVID researchers that when they see micro clots, they do things like nattokinase or lumbrokinase, or some might even do triple anticoagulation therapy with like hardcore anticoagulants. Do you have favorite ways that you address people who have this kind of issue?

Dr. Robert Groysman: Yes. So [00:47:00] endothelium is very much linked to mitochondrial function, okay, so you have to deal with oxidative stress no matter what else you do. So that, that's number one. Number two, you want to repair the endothelium, okay? Yes, it's important to break up these clots and nattokinase, lumbrokinase, they're, they're, they're fine to do that, but you also need to repair endothelium, otherwise it's gonna come back as soon as you stop those medications or supplements. Now, I, I don't usually use triple anticoagulant therapy because I think the risk is too high for the benefit.

Jill Brook: And that's what we've been hearing from people is they've been having some issues with bleeding.

Dr. Robert Groysman: Yeah. So I know somebody who had a bleed in their head and that requires hospital and surgery.

Jill Brook: Yeah.

Dr. Robert Groysman: So because the, because the risk is, if the risk is higher than the benefit, then I don't like to use that. Another thing we didn't really discuss is [00:48:00] platelets. So platelets tend to be stickier, okay, when, when it's under long COVID. And there, there's various reasons for that, but they're more likely to start a clotting process. With endothelium, normally the inside surface of the blood vessels is very smooth and there's nothing really sticking out or poking out. But if there's damage, all of a sudden you're seeing the stuff behind endothelium, and that's what starts the clotting process.

Now your body thinks something's damaged, like a cut or something, so it starts to basically clot. It starts the platelets and the clotting factor starts to activate. But apixaban, Eliquis, is, is a very strong, direct anticoagulant. Okay. So again, it's, it's about, it's about risk versus benefit. There is endothelial damage, there is micro clots. As far [00:49:00] as what they contribute to long COVID is not completely clear. I know it's a controversial thing and in the beginning, I, I didn't really buy into it. And the reason is, is because a lot of conditions like diabetes for instance, you have micro clots in diabetes, type two diabetes.

Okay. Yet nobody really looks for them or treats them with anticoagulant therapy or antiplatelets. And you don't see people keeling over from micro clot issues. They may have heart attacks and strokes, but not not the micro clot stuff. So, and there's other conditions that also carry micro clots with them.

So for me, it wasn't really clear how it, why would it be different in long COVID? But with further research, I realized that the amount of endothelial damage and the amount of micro clots was much higher than these other conditions. So now it became clinically relevant, whereas before it wasn't. So that's why [00:50:00] I included it in my series, in my book series.

It's number six. So, so yes, it's, it's, it's involved enough now with evidence for me to talk about it. So, yes endothelium is really hard though, to just diagnose by looking at someone.

The other ones are much easier. The other ones have like clear symptoms that will usually point to the mechanism, but I told you every single symptom, every single one, I can explain with all six. No matter how esoteric it is, in fact, I'm, I'm, I'm producing or I'm, I'm writing, finishing, writing a huge two volume encyclopedia, that's gonna cover every single symptom in long COVID, and I'm gonna show you how each symptom is caused by, or contributed to by each mechanism. So I'm gonna break down every single symptom. Yes, every single one. I bet you can't think of one that is not in there, but, and I'm gonna show you how each mechanism is causing it. So without knowing what the primary [00:51:00] is for you, how are you treating it? I mean, are you treating endothelial? Are you treating mitochondria? Are you treating dysautonomia? Makes a huge difference because if you're treating the wrong mechanism, not a whole lot happens. Right? Since it's not something that's in your system.

Jill Brook: Wow, this sounds amazing. We're excited for that. I just realized I've kept you already longer than I said I would keep you. Can you just tell people a little bit more about your books and where they can find the existing ones and what, where your new ones will be when they come out?

Dr. Robert Groysman: Sure. Right now all the books are available on Amazon. You could search for my name, they'll pop up. The, the main books I have out now are the, the complete long COVID handbook series. There's gonna be seven volumes total. I'm still working on volumes five and six which is the mast cell histamine intolerance plus the endothelial.

The manuscripts are done, it's just about, takes a long time to edit them and make 'em all pretty and make [00:52:00] sure everything is accurate. I've also published a vagus nerve, vagus and trigeminal nerve stimulation book, which really dives deep into what stimulation is and how it works. And why, why it works.

And it's probably the greatest invention since sliced bread because you can use it in just about every condition. I mean between seizures, between chest pains and arrhythmias and, and even lupus and rheumatoid arthritis. And it's been used for some, some conditions like ulcerative colitis. And it, it works by cooling down the immune system, right?

Immune system hot, it makes for autoimmunity, right? It makes for inflammation. So, those are the, the top two that I have right now. So volume one is the kind of the main book. It summarizes everything, kind of brings [00:53:00] everything together. And volumes two through seven talk about each of the mechanisms, the six mechanisms that I mentioned.

And hopefully the gut book, by the way, the gut dysbiosis book should be published in the next week or so. But we are, we're transitioning away from Amazon to kind of a more independent publisher so that we can control the price a little better. Amazon is kind of a stickler on discounts and stuff like that.

In fact, they don't allow discounts on books. So, that can be found on the website.

Jill Brook: Great, and we'll put a link to that in the show notes so everybody can find it.

Dr. Robert Groysman: Yeah, covidinstitute. org. And like I said, we've applied, we've applied what I've learned to many other conditions, and it's almost surprising that it's actually working for other conditions. It's like, why didn't we think about this sooner? But really just kind of looking at it not from a symptom based disease. Looking at it from a mechanism based disease, it [00:54:00] really it really does change. So why does it change? Because mechanisms are root causes. So we're basically looking at the source of the problem, not the end product, right? The symptoms are just end products. We, by, by looking at the mechanisms, you're, you're, you're basically working on the root causes, which why, which is why, why it works, and which is why we have such high success rates treating all these conditions.

Look, we can, I told you we can spend a week talking straight and we still wouldn't get through all the material, I promise you. I'm really excited to get this encyclopedia reference books, but these are gonna be big heavy books. Okay, we're talking about eight by 10 hardcover and 400 pages each. Okay, there's a lot of material to cover. This is not something you're gonna be sticking in your purse. This is meant for reference. So you, you, you have something, you look it up and you figure, you, you learn what mechanisms are involved. That's really it. [00:55:00] So this is a one of a kind thing. I don't think anybody's ever done or attempted to do anything like this.

So we're talking about more than 230 symptoms. Like I said, I, I've, I've scoured every, every piece of literature and study to see, make sure I didn't miss any symptoms. And yeah, I'm excited about it.

Jill Brook: We're excited that you're excited about it. We're we're so glad, as you said that this dropped in your lap when COVID started. I mean, hooray for us to get your brainpower thinking about it.

I thought maybe you could just end by talking about your clinic. So if there's people who are listening who are wondering where is your clinic located? Do you do telehealth? Do you take insurance? Are you taking new patients?

Dr. Robert Groysman: So we're located in Plano, Texas. It's a suburb, well, more, more urban nowadays than before in in DFW area. We are accepting new patients. We do offer telehealth [00:56:00] in pretty much, around the world. I mean, I, I, I talk to patients from every state and from every country just about.

And haven't had anybody from Russia yet or Iraq or Iran. So if you're listening, give our clinic a call. But pretty much every other country besides that we've talked with or treated. So we don't accept insurance for long COVID. Why? Because insurance doesn't really cover most of the codes and, and, and time that's necessary to diagnose and treat.

I mean, if I were to accept insurance for, let's say, a visit, I would have to spend 15 minutes in order to be able to cover the, the costs necessary to run the clinic. I'd have to see way more patients. I'd rather spend, you know, 40, 45 minutes with a patient and actually get to the bottom of it then, then have to be forced to be within time constraints of insurance and the [00:57:00] procedures are not really covered.

So stellate ganglion is covered for pain. Okay, if you have CRPS, if you have stump pain, if you have other issues that are sympathetically mediated pain. If you have pain, they will cover. They don't cover PTSD, they don't cover long COVID stuff. They don't cover dysautonomia. EAT, they don't even have a code for, okay.

There's no code to even bill insurance for. So the the point is, is it's too cumbersome to, to work with insurance to get anything done, to be able to actually help anybody. So we just made a decision not to accept insurance for this.

Jill Brook: So if people were to come be a patient of yours, would it typically be a situation? Do people come for a week or do they come for a month or do they come once a week for, you know, how, I guess, how, how, how does somebody typically work with you or does it, does it all depend on that first meeting?

Dr. Robert Groysman: It depends on what we're treating. It always is gonna depend on what we're treating first. Not [00:58:00] everybody gets a stellate ganglion block or EAT procedure. Not everybody has dysautonomia, so we treat other things, some things that can treat remotely. So, it's kind of hard question to answer. If somebody's coming to, to me from far away, I, I'll try to get as much done within a day or two as I can that safely can be done.

But I mean, if we're doing EATs and you're coming from far away, I may say, you know, stay five days. I'll do one on day one and one on day five. We'll have a little bit of a gap. But you know, if you need more, you need more. I mean, you may have to come and stay for a month or two. I mean, some people do.

You, you have to do what you have to do. For stellates, like I said, some, some just need one set and they're good. Others are gonna need several. So it's really difficult to know until I talk to the person to see how long they would, you know, typically need to stay.

Jill Brook: Sure. That [00:59:00] first time you talk to them, can that be done via telehealth or does that have to be in person?

Dr. Robert Groysman: No, it could be done, it could be done through telehealth. So there's, there's really not a whole lot to examine except maybe for the rash, as I said. A lot of it is just history gathering and figuring out what, what triggers they currently have for each mechanisms, going through all their symptoms, going through all their labs, going through anything else that they've tried.

And a lot of times when people see me, they've tried pretty much the whole thing. I mean, everything. You know, stuff, some stuff that I don't even approve of, but because I think it's dangerous. But, nevertheless, you know, we have to kind of sort through everything first. Go through all their medical history.

I mean, remember, long COVID doesn't occur in isolation. You know, people still have high blood pressure and they have heart disease and you know, they have schizophrenia and they have all these other things that, kidney problems, that are not necessarily caused by long COVID, but are occurring together now with long COVID.

So you [01:00:00] need to kind of go through that too. And, you know, some people have kidney failure or are on dialysis, so you need to take that into consideration when you're choosing what, what to treat them with.

Jill Brook: Yeah, that might makes sense. Dr. Groysman, thank you so much for giving us so much time and so much information and hope with some of these new treatments that you have figured out. And and I just, I'm thrilled to make your acquaintance and to know that you are on team, I don't even know what to call that anymore, it used to be, you know, Team Dysautonomia and then Team Triad, and then Team Penad and Septad.

Dr. Robert Groysman: Well, I treat, I treat them all, so, but the last thing I'm gonna say is don't lose hope. There really is a way to recover or, or at least get into remission, okay. The, the point is, is even if you're bed bound and I having even trouble getting out of bed, if you are feeling really low or, or kind at the end of [01:01:00] your rope don't lose hope.

There really is a way to do this, okay. But it's very systematic, as I said, so don't give up.

Jill Brook: Wonderful. Wonderful. So again, we'll put Dr. Groysman's links in the show notes if you wanna find 'em. And Dr. Groysman, thanks a million for your time and for your brain power.

Dr. Robert Groysman: My pleasure. My pleasure, Jill.

Jill Brook: Thank you. Okay, listeners, that's all for today, but we'll be back again next week. Until then, thank you for listening, remember you're not alone, and please join us again soon.