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Acupuncture and Chinese herbs in the integrative management of post-COVID syndrome

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an RNA-type virus causing an acute respiratory infection (ARI) with different levels of severity ranging from a mild condition, like a common cold, to severe pneumonia and death. A clinical condition presenting 4–12 weeks after coronavirus disease 19 (COVID-19) infection, with persistent symptoms such as fatigue, cough, dyspnea, headache, myalgia, brain fog, and diarrhea, has been frequently recognized and is known today as post-COVID syndrome or long-COVID-19. Without a clear pathophysiology, research studies have proposed some secondary theories of SARS-CoV‑2 infection. This entity has also been studied from the perspective of traditional Chinese medicine, recognizing syndromes or patterns in the different stages or phases of the disease and emphasizing a more individualized treatment according to the predominant pathological condition. It is concluded that the integrative and complementary use of acupuncture and Chinese herbal medicine is highly effective and could be a main resource for the treatment of this syndrome.


Pathophysiology of COVID-19
Infection of the respiratory system by SARS-CoV-2 can be classified by the degree of severity into three phases that the patient can go through, depending on their health condition: • early phase or stage I • pulmonary phase or stage II • hyperinflammatory phase or stage III

Post-COVID syndrome Definition
The term "post-COVID syndrome" is defined as a multiorgan symptom complex which affects patients who have suffered from COVID-19 (diagnosis confirmed by laboratory tests) and persists with symptoms 4-12 weeks after the acute phase of the disease and is not explained by an alternative diagnosis. It is estimated to occur in 10-20% of patients, mainly in those who presented moderate to severe symptoms and required hospitalization and/or intensive care.

Pathophysiology hypothesis of post-COVID syndrome
Numerous studies have observed probable pathophysiological mechanisms that explain the persistence of symptoms: • virus persistence • inflammatory cytokine storm • existence of autoantibodies

Pulmonary effects
In up to 39% of patients, a persistent impairment in pulmonary diffusion and development of fibrosis is observed.

Effects on the musculoskeletal system
After viral replication, cell death, and activation of the inflammatory response, muscle fiber proteolysis is induced, in-creasing the proliferation of muscle fibroblasts.

Effects on the cardiovascular system
Cases with pericardial inflammation due to cytotoxic mechanisms, pericardial effusion, and tamponade have been observed.

Common signs and symptoms
• chest tightness • orthostatic hypotension • tachycardia

Effects on the neurological system
Expression of ACE2 in endothelial cells of the brain and the inflammatory response cause the virus to directly damage the blood-brain barrier (BBB), spreading to the brain through synaptic transfer.

Traditional Chinese medicine approach to COVID-19
Within the framework of traditional Chinese medicine (TCM), three types of pathogenic factors are described: 1) external pathogenic factors, 2) internal pathogenic factors (overexcitement or disturbance of emotions), and 3) miscellaneous factors.
The existence of another pathogenic factor termed "febrile pathogenic factor" or "epidemic pathogenic factor, " which often represents severe or epidemic viral diseases, is recognized.
Severe viral infection usually manifests with fever and can affect the pulmonary system severely as well as the entire body; in particular, it can potentially become a highly contagious and epidemic disease, as in the case of COVID 19.
Thus, according to Chinese medicine, COVID-19 falls under the category of an epidemic febrile disease (wen bing 温病). It has been studied as the very intense invasion of the body by a heat pathogen and is commonly described as very aggressive, destructive, and toxic (toxic heat). This febrile disease (wen bing 温病) receives special attention, and specific diagnostic and treatment criteria are established based on an evolutionary process of four layers or levels: 1) wei "defensive" (wei fen 卫分), 2) qi "energetic" (qi fen 气分), 3) ying "nutritive" (ying fen 营分), and 4) xue "hematic" (xue fen 血分).
This way of evaluating the disease allows us to determine the level of penetration of the pathogen (toxic heat), the acuity, and the severity of the disease. The deeper, the more serious, and consequently the more difficult the treatment, the more likely it is to generate multiorgan damage, sequelae, post-COVID syndrome, and death.
Generally, epidemic febrile disease is characterized by a high degree of virulence and toxicity. Depending on the intensity (toxicity) and depth (level), it is possible for the patient's body to defend itself (strong antipathogenic energy) and recover, especially if it is provided with adequate and timely care in a comprehensive manner.

Correlation of COVID-19 phases with febrile disease levels and post-COVID syndrome
Based on the above, we can consider that COVID-19 is an epidemic febrile disease and, according to each patient's clinical condition, the following phases could be considered:

Phase 0 (preventive/no infection)
People are generally healthy or without evident disease and have resulted negative in a COVID 19 test. One could offer a preventive treatment to enhance the immune system and decrease the risk of becoming infected by COVID19.

Phase 1 (mild)
The patients in this phase were mostly affected at the "wei level" and frequently remain asymptomatic. Patients who become "symptomatic" in this phase generally re-infection. This entity has also been studied from the perspective of traditional Chinese medicine, recognizing syndromes or patterns in the different stages or phases of the disease and emphasizing a more individualized treatment according to the predominant pathological condition. It is concluded that the integrative and complementary use of acupuncture and Chinese herbal medicine is highly effective and could be a main resource for the treatment of this syndrome.

Keywords
Post COVID Syndrome · Traditional Chinese Medicine · Febrile disease · Integrative management · Acupuncture

Schlüsselwörter
Post COVID Syndrom · Traditionelle chinesische Medizin · Fieberhafte Erkrankung · Integrative medizinische Versorgung · Akupunktur cover fully in a short time and only some are left with sequelae or post-COVID syndrome. Those "asymptomatic" and those who were treated opportunely with acupuncture and/or Chinese herbal medicine have a low or zero probability of developing post-COVID syndrome (see below).

Phase 2 (moderate)
In this phase, the "febrile pathogen" has gone deeper, affecting the qi level. Patients who go through this phase often have some sequelae or post-COVID syndrome (see below). However, those who were treated with acupuncture and/or Chinese herbal medicine, in addition to integrative and complementary management with modern medicine, recover more quickly, with less chance of developing post-COVID syndrome or, if it does occur, it will be less severe.

Phase 3 (severe)
In this phase, the "febrile epidemic pathogen" has reached the "ying" and "xue" levels. Patients who go through this phase frequently develop a severe condition, or stage III in Western medicine. Patients who go through phase 3 take longer to recover despite the various aggressive treatments with drugs and hospital care. They can hardly be treated opportunely with acupuncture and/or Chinese herbal medicine (some were able to incorporate herbal medicine, which contributed to a better and faster recovery). These patients will most often be left with sequelae or post-COVID syndrome (see below).

Post-COVID syndrome in traditional Chinese medicine
According to TCM, this syndrome is more prevalent in patients who had been affected by the "febrile qi" at the qi, ying, or xue levels (COVID 19 phases 2 and 3), as well as in those who did not receive comprehensive and complementary treatment with acupuncture and/or herbal medicine opportunely.
Febrile disease in general and also CO-VID 19 can leave certain predominant deficiencies that will depend on the severity of the infection as well as on previously suffered conditions and individual predispositions. However, the main pathophysiological conditions that might occur with COVID infection and determine generation of the different post-COVID syndrome patterns are residual heat, fluid consumption, yin deficiency, residual phlegm, and blood stagnation, as well as deficiencies of lung, spleen, kidney, and heart, liver qi stagnation and liver yang increase.
A careful evaluation should always be made, and individualized treatment offered. Therefore, it is possible to identify some characteristics common to most patients as well as some predominant patterns that allow us to establish more specific treatments.

Treatment of post-COVID syndrome with acupuncture and Chinese herbs
As mentioned above, treatment of this syndrome should be based on a careful and individualized evaluation. Thus, the acupuncture points and Chinese herbal formulas will be structured accordingly.
There are two components of the treatment: 1) general (but individualized), to address the common pathophysiological process (Fig. 1); and 2) individualized, to address the predominant pattern.
Chinese herbs. Products that reinforce the above therapeutic principles will be included in the master formulas recommended for each predominant pattern.

Treatment according to the predominant pattern
Treatment according to the predominant patter comprises the following elements: a) tonify spleen; b) tonify lung; c) tonify kidney; d) tonify heart; e) restrain the yang of the liver.

Predominance of spleen qi deficiency
Patients who suffered COVID phase 2 or 3, who, in addition to presenting chro-nic residual heat and consumption of liquids and yin, were left with spleen deficiency.
Tongue. Slightly pale, with a slightly greasy coating. According to chronicity with dental impressions. Therapeutic principle. Nourish and revitalize the spleen-stomach system.

Acupuncture treatment
Zhongwan 中 脘 (RM12). Regulates the function of the central heater, strengthens the spleen, promotes the elimination of dampness, regulates the dynamics of the energy of the stomach.
Sanyinjiao 三阴交 (SP 6). Tonifies the spleen and stomach, favors the distribution transformation process, drains the channels, promotes the collaterals, regulates and harmonizes blood and energy, nourishes the blood.

Predominance of lung deficiency
The tropism of SARS-CoV-2 for the pulmonary epithelium, and in relation to the theory of the persistence of the virus, the fact that the epidemic febrile pathogenic factor was not completely expelled generates a condition of residual heat, causing deficiency of lung qi.
If the qi is weak or insufficient, the descent and dispersion of the lung is disturbed, causing stagnation of organic liquids and accumulation of phlegm, if not resolved, the residual heat exacerbates the stagnation of phlegm, which will increase the consumption of liquids that will lead to the consumption of yin. Persistent symptoms. Dry cough, constitutional weakness, dyspnea, tiredness, weak voice, daytime sweating at rest.
Tongue. Slightly red and dry, cracks.

Acupuncture treatment
Zhongfu 中府 (LU 1). Favors the process of diffusion of the energy of the lung, regulates the dynamics of the energy, mobilizes the liquids.
Feishu 肺俞 (BL 13). Tonifies qi of the lung, promotes the diffusion process of lung energy, controls cough, favors the circulation of energy.

Sanzhong 膻中 (RM 17). In tonification.
Regulates the dynamics of energy, favors the process of diffusion of lung energy and controls its rebellious energy, expands the chest and transforms phlegm.
Chize 尺泽 (LU 5). Cools the heat of the lung, lubricates the lung, promotes the descent process, and regulates the dynamics of lung energy.
Tiantu 天突 (RM22). Favors the lung purification process, controls cough, lowers the rise of rebellious energy, transforms phlegm, cleanses and lubricates the throat.

Fig. 1 Pathophysiological process of post-COVID syndrome
Taiyuan 太渊 (LU 9). In toning. Eliminates Hegu 合谷 (LI 4). Cools the hot energy of the energetic qi region (in febrile illnesses). Promotes blood circulation, stops headaches, harmonizes the rise and fall of qi.

Concluding remarks
The use of acupuncture and Chinese herbs in the management of patients with CO-VID-19 and post-COVID at the Guijing Integrative Medicine Center since the start of the pandemic in 2020 has allowed us to study and observe the behavior, evolution, and therapeutic response, as well as to accumulate valuable experiences to contribute to better integral treatment and control of this type of illness.
It is agreed that one of the most important functions and contributions of acupuncture and Chinese medicine in relation to COVID 19 and other viral diseases lies in its immunomodulatory, immunopotentiating effect, highlighting its value both in prevention and in risk reduction of contagion, as well as for decreasing the severity of the clinical condition in case of contracting the SARS CoV-2 infection.
Many of the patients who were treated with acupuncture and/or Chinese herbal medicine opportunely were not infected, and those infected remained asymptomatic or only developed mild symptoms.
In patients who were able to receive treatment with acupuncture and herbal medicine in combination with conventional medicine, a much faster and more favorable evolution was observed, considering that there was also a decrease in the occurrence of post-COVID syndrome.
It is important to point out that elaboration of individualized herbal formulas was often provided, designing the formulas based on the clinical information obtained electronically as well as on a pic-ture of the patients' tongue to establish the diagnosis and the therapeutic principle appropriately. In this way, the herbal formula was prepared and sent to their home.
In patients who had had severe symptoms only until they came out of the severe stage, an integral treatment with acupuncture and herbal medicine could be implemented, which also contributed to a faster and better recovery. Among these patients is where a large number developed post-COVID syndrome. More recently, with the easing of health restrictions, we have been able to attend to many more patients with post-COVID syndrome.
With the code of Chinese medicine, it is possible to make an integral diagnosis where a syndromic pattern is recognized and a more individualized treatment can be established, while maintaining common and general criteria to establish treatment models with acupuncture and Chinese herbs.
In our experience, we can conclude that a high percentage of patients with various modalities of the post-COVID syndrome treated with acupuncture and/or Chinese herbal medicine obtained a considerable improvement in the short term, mainly in patients who suffered the mild phase of COVID 19 or who were treated promptly in the moderate or severe phases.
In addition, it is important to point out that in the integral management of the post-COVID syndrome, the main therapeutic resource has always been acupuncture. The use of complementary Chinese herbal medicine is indicated predominantly for those more delicate and persistent cases.
A more detailed, specific, and deep analysis of all the elements of theory, diagnosis, and treatment according to Chinese medicine and integrative medicine exceeds the objectives of this article and will be reserved for future work.