Solving the Puzzle: The Ross Long COVID Management Guide

Long COVID Symptoms & Root Causes

Long COVID, clinically named post-acute sequelae of SARS-CoV-2 infection (PASC), refers to the mess of symptoms that persist for months after the initial COVID-19 infection has resolved, sometimes following a mild case or even an asymptomatic one. For some patients, symptoms ease gradually over time. For others, the condition becomes a chronic, disabling illness that can last years.

Patients most commonly report:

Profound fatigue that isn’t relieved by rest
Post-exertional malaise: a worsening of symptoms after physical or mental exertion, sometimes delayed by a day or more
Brain fog, including trouble concentrating, word-finding difficulty, and short-term memory lapses
Shortness of breath or chest tightness
Heart palpitations or a racing heart, particularly on standing
Sleep that feels unrefreshing despite adequate hours
Joint and muscle pain
Lightheadedness or fainting spells
Digestive symptoms such as bloating, nausea, or altered bowel habits
Loss of or altered smell and taste

Long COVID is a condition with many root causes that may vary by person, including:

Reactivation of dormant infections such as Epstein-Barr virus, Bartonella, Babesia, or Borrelia
Persistent COVID virus or spike protein that the immune system hasn’t fully eliminated
A nervous system locked into a chronic threat-and-inflammation response
Disrupted hormonal signaling
An imbalanced gut microbiome
Immune dysfunction
Mitochondrial function that falls short of the body’s energy requirements
Autonomic nervous system dysfunction, manifesting as tachycardia or fainting spells
Mast cell activation syndrome, driving inflammatory and allergic symptoms
Vascular endothelial dysfunction, which, in many patients, restricts blood flow or produces microclots that quietly deprive tissues of oxygen

Solving the Puzzle of Long COVID: A Root Causes Approach

While research identifies the various root causes of Long COVID, there is only one study completed to date (as of time of writing: July 2026) that shows that a multi-faceted approach which addresses many root causes at the same time can improve the health of people living with Long COVID. The study was conducted by OvationLab plus ANDHealth.

OvationLab-ANDHealth Post Viral Recovery Program Provides Direction

The Ross Long COVID Management Guide included later in this article builds on the pioneering work of OvationLab with ANDHealth (OLAH). In 2022, OLAH convened a group of experts to review the literature to develop a root causes approach to addressing Long COVID. As part of their work, they collected data on 100 people who are using a Long COVID support approach they developed.

At the American Academy of Anti-Aging Medicine (A4M) conference in Las Vegas in December 2023, OLAH and its panel of experts presented results on their approach. Unfortunately, OLAH never published its findings. According to the panel presentation, about 50% of people completing the three-month OLAH protocol became Long COVID symptom free. OLAH analyzed data of 40 people enrolled in their registry.

That analysis shows functional status changes from 2 to 1.2 on a 4-point scale, representing a 38.5% improvement. In addition,

fatigue levels improved 30%,
anxiety decreased 20%,
depression improved 27%,
sleep disturbances decreased 23%, and
pain interference decreased 15%.

From what I can tell, these reported improvements include data for the 50% of people who became COVID symptom free.

The OLAH study showed that a limited root causes approach can improve the health of people living with Long COVID.

OLAH Post Viral Recovery Program

The OLAH approach included a program of lifestyle interventions and nutritional supplements. Here are the basic components:

A plant-based diet using the Whole 30 Program, which emphasizes colorful and nutrient dense foods, quality proteins, and healthy fats while removing processed foods and drinks.
Restorative sleep.
Movement and exercise to tolerance, emphasizing taking it slow by starting small and pacing activity.
Stress modification through activities like meditation, support through others, being physically active, spending time in nature, gratitude practices, play, and creative expression in music and art.
Social connection through support groups, family, friends, and other person-to-person interactions.
A program of core and additional nutritional supplements targeting ACE-2 receptor damage of the vascular endothelial glycocalyx hurting blood flow, viral persistence, chronic inflammation, mitochondria injury, and gut microbiome imbalance.

The Ross Management Guide Expands the Root Causes over OLAH

The Ross Long COVID Management Guide addresses additional root causes that were not identified in OLAH. These include:

Reactivation of Bartonella, Borrelia, or Babesia.
Persistence of the COVID spike protein leading inflammation, immune dysfunction, and autonomic dysfunction through interactions with acetylcholine receptors.
Immune dysregulation unrelated to gut microbiome dysfunction, mitochondrial dysfunction, and chronic inflammation.
Serotonin depletion caused by COVID-19 and/or gut microbiome dysfunction leading to mood disorders and autonomic dysfunction.

About The Ross Long COVID Management Guide

Given the shortcomings of the OLAH approach, I developed an improved post viral recovery program. This management guide is based on my own observations and success managing people with Long COVID in my Seattle practice, the OLAH experience, and my review of the ever-emerging science.

Action Steps in The Ross Long COVID Management Guide

Part A: Lifestyle Modifications

The Ross Management Guide includes the following helpful lifestyle modifications and action steps from OLAH.

I cannot stress the importance of these steps enough. To implement these steps, work with a functional medicine health professional. You may also want the help of a health coach or even a nutritionist.

Eat a plant-based diet using the Whole 30 Program, which emphasizes colorful and nutrient dense foods, quality proteins, and healthy fats while removing processed foods and drinks.
Get restorative sleep through lifestyle modifications or sleep-inducing herbal medicines. For more information, see The Ultimate Sleep Guide for Lyme, Tick-borne Diseases, and Mold Toxicity and Sleep: The Natural Medicines.
Move and exercise as tolerated, emphasizing taking it slow by starting small and pacing activity.
Modify stress through activities like meditation, getting support from others, being physically active, spending time in nature, gratitude practices, play, and creative expression in music and art.
Connect socially through support groups, family, friends, and other person-to-person interactions.

Part B: Nutritional Supplements & Medications

Part 1: Reactivation of Dormant Infections

1. Bartonella, Babesia, or Borrelia. In my experience, Bartonella often reactivates in Long COVID. But I have also seen Babesia and Borrelia reactivations.

Testing is not perfect. For a person who has tested positive for these infections in the past, I base my management decisions on the types of Bartonella, Babesia, or Borrelia symptoms that were present before. In reactivated tick-borne infections, testing is not reliable.

If you have not been diagnosed with these infections before, testing can be reliable.

Make a clinical decision. Work with a Lyme Literate Medical Doctor to help figure out if you have active tick-borne infections considering your symptom profile and testing results. Be aware, there is not a definitive test to prove you have reactivated infections.

As a starting point, when tick-borne infections reactivate, I like to work with herbal antibiotic regimens rather than prescription antibiotics to prevent further intestinal microbiome disruption originally triggered by COVID. It is possible to use the following herbal antibiotics simultaneously to manage Bartonella, Babesia, and Borrelia at the same time.

Cryptolepis: 5 ml (1 tsp) 3 times a day by starting at 1 time a day and increasing every other day, if tolerated, to 3 times a day.
Japanese Knotweed: 5 drops 2 times a day of each herb, increasing the dosing every day by 1 drop per dose until taking 30 drops 2 times a day. Taking on an empty stomach is best. Do not take 30 minutes before through 2 hours after having food, medicines, or supplements. If you get a Herxheimer die-off reaction, do not advance the dose until it decreases.
Liposomal Cinnamon, Clove, and Oregano Oil Combination: 1 pill 2 times a day.

Additional Resources on Tick-borne Infections

Diagnosis

Tests

Management with Herbal or RX Antibiotics

2. Epstein Barr Virus (EBV). There are a large number of studies suggesting reactivated EBV contributes to Long COVID. Work with your healthcare provider to measure antibodies or quantitative PCR testing to see if EBV is reactivated.

Testing is not perfect. A marked elevation of EBV viral load measured with a quantitative PCR test may indicate active infection. Antibody elevation of IGG early antigen (EA IGG) with either elevation of viral capsule IGG (VCA IGG) or Epstein Barr nuclear antigen IGG (EBNA IGG) can indicate active infection too.

Make a clinical decision. Testing only indicates if reactivated EBV is possible. But there is no definitive test. If the PCR test is elevated or antibody testing is suggestive, then I suggest a 6 month trial to lower EBV viral load.

Choose one of the following management options to lower EBV germ load. Work with either one for six months to see if they will help.

Valcyclovir (Valtrex)* 1000 mg: 1 pill 3 times a day OR
Olive Leaf Extract 500 mg: 1 pill 3 times a day, advancing up to 1500 mg 3 times a day as tolerated. Be aware killing EBV may cause a Herxheimer die-off reaction that can make you feel worse. That is why I have my patients start low at 500 mg 3 times a day and advance the dose as tolerated.

Part 2: COVID Virus or Spike Protein Persistence

Persistent COVID spike protein or chronic pockets of COVID infection may lead to ongoing inflammation and immune system dysregulation. Research studies confirm pockets of chronic COVID infection in some individuals.

Testing is not perfect. At this time, we do not have accurate testing to prove chronic infection or to prove spike protein illness. I rely on COVID spike antibody (IgG) semi-quantitative testing and COVID nucleocapsid antibody (IgG) qualitative testing. A marked elevation in spike antibody IGG with negative nucleocapsid IGG suggests spike protein illness. A marked elevation of spike antibody IGG with positive nucleocapsid IGG suggests chronic infection.

Make a clinical decision. Testing does not confirm active virus or spike protein. But positive testing does suggest the possibility of one or both of these problems.

Manage spike protein. For elevated spike protein, studies suggest nattokinase may help break down spike protein. Nattokinase is an enzyme that breaks down fibrin blood clotting protein and other proteins. It is derived from soy. As an alternative, lumbrokinase, an enzyme derived from earthworms, may help in people with soy allergies.

Nattokinase 100 mg OR Lumbrokinase 20 to 22 mg: 1 or 2 pills 1 time a day or 1 pill 2 times a day. Take on an empty stomach (without food or meds or supplements) by 1 hour either side (water is allowed).

Persistent virus. Studies on prescription Paxlovid for COVID virus show no improvement. While some practitioners use Ivermectin to kill COVID, in my opinion and experience, the science does not support this approach either. While some may feel better on Ivermectin, this is likely due to its anti-inflammatory effects rather than viral killing capabilities. I continue to watch the science to see if an effective anti-viral approach will emerge.

Part 3: Brain Threat & Inflammation Response

The immune cells that fight infection in the brain are called microglia. The microglia make excessive inflammation chemicals called cytokines that lead to inflammation and immune system dysregulation. In addition to COVID infection and spike protein, intestinal microbiome disturbances may lead to increased microglia activity. Low dose naltrexone (LDN) is effective at limiting microglia inflammation, modulating the immune system, and helping with mast cell activation.

For some with Long COVID, part of the brain called the limbic system gets stuck in an “on” position. This can lead to a chronic holding of symptoms in the body. There are programs that retrain this area of the brain to let go. Some studies suggest a symptom reduction of 50% in people living with chronic fatiguing illnesses.

Low Dose Naltrexone* 1.5 to 4.5 mg: 1 time a day. Use it for a minimum of 6 months to see if it is effective. Start at 1.5 mg 1 time a day in the morning for 2 weeks, then increase to 3.0 mg 1 time a day for 2 weeks, then increase to 4.5 mg 1 time a day. LDN is a prescription made by compounding pharmacies.
Brain retraining with Gupta Program: For brain retraining to help the limbic system let go, I recommend the Gupta Program to my patients. Alternative programs include Primal Trust and the Annie Hopper Dynamic Neural Retraining System.

Part 4: Disrupted Hormonal Signaling

Cytokine inflammation from the immune system reaction to COVID can disrupt regulation of the hormonal systems. Curcumin and glutathione may lower excess cytokines. Ashwagandha is an Ayurvedic and Chinese medicine herb that supports the correct function of the adrenals and thyroid glands. It is also an adaptogen that helps deal with physical and emotional stress. I also suggest thyroid plus female and male hormone testing. For thyroid testing, I test for t4, t3, tsh, and reverse t3. For more on thyroid testing, see It’s Tricky—How to Diagnose & Manage Low Thyroid.

Liposomal Glutathione 400 to 500 mg: 1 time a day for 90 days.
Liposomal Curcumin 500 mg: 1 pill 3 times a day for 90 days.
Ashwagandha 400 to 500 mg: 2 pills in the morning and 2 pills between 1 to 2 pm.

Part 5: Imbalanced Intestinal Microbiome

COVID causes major disruption in the balance of good bacteria in the intestinal microbiome. Because the intestinal microbiome directs every organ system in the body, including the brain and immune system, fixing the intestinal microbiome is key to recovery. Probiotics, prebiotic fiber, and polyphenols promote a healthy microbiome. If you do not eat a plant-forward diet, then be sure to supplement with polyphenols and prebiotics. (Note: To provide the best direction to gut recovery, get a comprehensive stool test through Jona Health.) If you do not have Jona stool testing, then you can do the following.

Akkermansia + Butyrate Producers Probiotic Blend: 2 pills 1 time a day. (Butyrate producing probiotics can include Bifidobacterium, Anaerobutyricum hallii, Clostridium beijerinckii, and Clostridium butyricum.)
Polyphenol: 2 capsules one time a day.
Prebiotic: non-digestible sugars, 1 to 2 pills 3 times a day.

For more information, see Your Guide to a Healthy Intestinal Microbiome—Even on Antibiotics.

Part 6: Immune Dysfunction

COVID leads to immune dysfunction and cytokine inflammation excess. Work to lower cytokines with supportive glutathione and curcumin. In addition, LDN may increase TReg white blood cells that create balance in TH1, TH2, and TH17 inflammation.

Low Dose Naltrexone* 1.5 to 4.5 mg: 1 time a day. Use it for a minimum of 6 months to see if it is effective. Start at 1.5 mg 1 time a day in the morning for 2 weeks, then increase to 3.0 mg 1 time a day for 2 weeks, then increase to 4.5 mg 1 time a day. LDN is a prescription made by compounding pharmacies.
Liposomal Glutathione 400 to 500 mg: 1 time a day for 90 days.
Liposomal Curcumin 500 mg: 1 pill 3 times a day for 90 days.

Learn more in Control Cytokines to Improve Symptoms & Immune Health, Low Dose Naltrexone (LDN), Boost Tregs to Balance Th1, Th2, & Th17 Chronic Inflammation and Autoimmune Disease.

Part 7: Mitochondrial Function

COVID triggers the immune system to make excess oxidation chemicals that may injure the mitochondria cell energy factories. Supporting repair of the mitochondria with a phospholipid mix that contains key mitochondrial micronutrients is helpful. Preventing oxidative damage with glutathione may help.

Phospholipid Mix + CoQ10 + PQQ: 3 pills 1 time a day. Use for 6 months. (Key ingredients include multiple phospholipids, various mitochondria micronutrients, CoQ10, and PQQ.)
Liposomal Glutathione 400 to 500 mg: 1 time a day for 90 days.

Learn more: Power Up Your Mighty Mitochondria & Get Energy.

Part 8: Autonomic Nervous System Dysfunction

Racing of the heart, shortness of breath, and fainting or near fainting easily on standing are seen when COVID leads to autonomic nervous system dysfunction. Nicotine may help by attaching to acetylcholine receptors occupied by the spike protein. This improves acetylcholine signaling to help the autonomic nervous system. 5 hydroxy-tryptophan improves the production of serotonin in the gut lining. 95% of the body’s serotonin is made in the intestines. COVID damages serotonin production. Serotonin improves autonomic function.

5-Hydroxytryptophan (5-HTP) 100 mg: 1 pill 3 times a day.
Nicotine patch 7 mg: ½ daily for a week. If not effective, consider increasing to 14 mg.
Increased Salt & Fluid Intake: Increasing salt and fluid intake can improve blood volume and circulation, reducing symptoms like dizziness and fatigue.
Medications: Beta-blockers and Midodrine may help regulate heart rate and improve blood flow.
Ashwagandha 400 to 500 mg: 2 pills in the morning and 2 pills between 1 and 2 PM promotes better adrenal function leading to improved water retention in the vascular space.
Compression Garments: Wearing compression stockings can aid in maintaining blood circulation, alleviating fatigue.

Part 9: Mast Cell Activation Syndrome

COVID turns on mast cells to produce histamines seen in allergic reactions and to produce excess cytokines. If you have increased allergies to pollens or food, or have developed hives or eczema rashes, you likely have Mast Cell Activation Syndrome as part of Long COVID. LDN binds to mast cells to stabilize them. The herb quercetin also promotes healthy mast cell function. I start with these two first. If they are not effective, then I consider adding ketotifen.

Low Dose Naltrexone* 1.5 to 4.5 mg: 1 time a day. Use it for a minimum of 6 months to see if it is effective. Start at 1.5 mg 1 time a day in the morning for 2 weeks, then increase to 3.0 mg 1 time a day for 2 weeks, then increase to 4.5 mg 1 time a day. LDN is a prescription made by compounding pharmacies.
Quercetin 250 mg: 2 pills 3 times a day.
Ketotifen 1 mg*: 1 pill 2 times a day. This is a prescription that has to be made by a compounding pharmacy.

For additional supportive supplements and prescriptions, see Mast Cell Activation Syndrome in Infections & Mold Toxicity.

Part 10: Vascular Endothelial Dysfunction

COVID spike protein receptors are located on the blood vessel endothelial glycocalyx (EG). The EG covers endothelial cells that line the blood vessel walls. EG injury can decrease the production of nitric oxide in blood vessels. Nitric oxide improves blood flow and is anti-inflammatory. Injured EG may lead to vascular microclots. Rhamnan sulfate extract from Monostrum Nitidum seaweed supports repair of the EG. Lumbrokinase or Nattokinase are enzymes that may break-up microclots.

Rhamnan Sulfate Extract: 2 capsules, 2 times daily for 30 days, then 1 capsule 2 times a day for 60 days.
Nattokinase 100 mg OR Lumbrokinase 20 to 22 mg: 1 or 2 pills 1 time a day or 1 pill 2 times a day. Take on an empty stomach (without food or meds or supplements) by 1 hour either side (water is allowed).

Disclaimer*

We recommend you discuss these ideas with your healthcare provider before starting them.

The use of ketotifen, naltrexone, and valtrex mentioned in the article are off-label uses. The FDA has not approved the use of these medications for the conditions mentioned in this article.

The ideas and recommendations on this website and in this article are for informational purposes only. For more information about this, see the sitewide Terms & Conditions.

Top 6 Most Important Resources