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Hyperbaric oxygen therapy in the treatment of Traumatic Brain Injury.

I am one of the Principal Investigators on the National Brain Injury Rescue & Rehabilitation (NBIRR) project. The results of this project will forever change the way brain injury is treated. So far, we have focused our attention on veterans coming back from Iraq and Afghanistan for several reasons beyond the great need for these men and women to be healed for their sacrifice in the service of our country. [The NBIRR-01 Study is IRB-approved. The Study is listed at www.ClinicalTrials.gov. The National Call Center Number is: (800) 288-9328].

First, there are about 600,000 Iraq and Afghanistan war veterans with blast/concussion casualties. Each casualty costs approximately $60,000 per year including safety net services from substance abuse or incarceration costs, as well as lost tax revenue. For every active duty Soldier. Sailor, Airman or Marine that is treated there is a corresponding $2.6 million saved per veteran over their lifetime because they are better able to assume productive roles in society, become employed, pay taxes and raise families. So, addressing their silent but challenging disorders is of paramount importance to the nation, makes good economic sense and is a moral obligation of our society. These men and women who have chosen to go in harms way and now suffer from hidden wounds of war like depression, anxiety, TBI and PTSD present a significant national emergency, and while there are other national emergencies, such as the autism epidemic (an environmentally and genetically triggered disorder), veterans with TBI/PTSD have made their needs well known to society and the government, including the devastating costs associated with not treating them. In addition, there are 120 veteran suicides per week (as per the CDC), a staggering number unparalled in previous conflicts the U.S. has been engaged in.

Now, there are still many who do not believe it is possible to affect biological repair in a brain injury, but the truth is there has been an approved treatment for many years. Hyperbaric oxygen therapy (HBOT) is the only non-hormonal treatment approved by the FDA for biologically repairing and regenerating human tissue. It is currently FDA-approved as the primary treatment for 4 different kinds of brain injuries: carbon monoxide poisoning, arterial gas embolism, cerebral decompression sickness, and cranioradionecrosis (radiation damage to the brain after cancer radiotherapy).

Almost 50 subjects have completed the NBIRR protocol under IRB supervision, which means subjects have been getting treated with oxygen under pressure HBOT 1.5 (one and a half atmospheres) for 60 minutes a day.

During the first 1/2 of the protocol, amounting to 40 treatments, HBOT at 1.5, 100% of everyone who completed 40 treatments improved. 80% of those treated were able to return to duty work or school. 55% of those treated are no longer using their black-boxed (increases suicide) prescription medications when they finish the 40 treatment protocol. 45% of those who are still in need of medication have reduced that medication use dramatically. Suicideality vanished almost completely!

Paul Harch, MD, and the author of The Oxygen Revolution, in a pre-NBIRR LSU IRB-approved study, showed that 15 blast injured veterans improved with great statistical significance using just the first part of the NBIRR protocol. There was a 15 point IQ jump in 30 days (p<0.001); 40% improvement in Post-concussion Syndrome symptoms (p = 0.002); 30% reduction in PTSD (p.001); 51% reduction in depression (p<0.001). [The P values on more patients have now been submitted to publication and have moved yet another decimal point in significance.]

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HBOT 1.5 is synergistic with other benign treatments being used for TBI, such as cognitive rehabilitation and acupuncture, but the difference with HBOT is these ancillary treatments will produce better results because they are now building upon the biological repair brought on by the HBOT. There is a misconception in medicine today that the use of HBOT creates a placebo effect. Today, we know that HBOT activates 8,100 genes. Placebos do not activate genes, especially ones involved in inflammation, growth and repair of human tissue!

HBOT has been treating brain injuries as far back as 1963, when it was first found effective in treating carbon monoxide poisoning.[1,2] Although the misconception that HBOT is only treating carboxy-hemoglobin persists to this day.[3] Brain injuries caused by decompression sickness and arterial gas emboli began being treated by HBOT using Navy Treatment Table six.[4,5] Delayed treatment (3 months) of an ischemic stroke with HBOT was reported by the US Navy in 1969.[6] Subsequently, successful treatment with HBOT for late treatment of a stroke, diabetic encephalopathy and near-drowning/global anoxia was also reported[7] with the additional evidence of pre and post functional brain imaging (SPECT). The medical literature continues to grow showing HBOT is efficacious in treated old carbon monoxide poisoning (COP) also known as delayed neuropsychiatric syndrome (DNS) of COP. [8,9]

While the historic literature points to HBOT as being efficacious for many conditions, HBOT is an orphan therapy that falls outside of the medical paradigm where drugs and interventions are selectively fed into the standard-of-care/reimbursement complex by corporate interests that control both medical information and clinical practice trends. A therapy that exists outside our dysfunctional medical paradigm tends to be but a footnote that is passed over, buried or ignored completely.

Despite controlled randomized trials demonstrating HBOT's efficacy for treating TBI, ignoring HBOT for treating brain injuries seems to have become codified even though other forms of intervention have fallen short. High quality clinical trials demonstrating the efficacy of HBOT in brain injury eventually get buried or forgotten.

While in acute severe TBI, HBOT has been shown to be effective in reducing mortality, [11] Harch et al demonstrated consistent SPECT brain imaging improvements (showing improved brain blood flow) in chronic TBI patients treated with HBOT 1.5. [12,13,14,15] Since the original work of Drs. Neubauer and Harch, the efficacy of HBOT 1.5 in a chronic stable TBI has been well documented. [16,17] Patients with abnormal functional brain scans secondary to TBI show consistent improvement after HBOT 1.5.

Recently, Harch et al reported dramatic improvement in a series of 15 patients treated with HBOT 1.5 in a clinical trial of military related TBI. [18] Functional brain scans continue to document results for HBOT 1.5 for combat related and blast related TBI. [19] In two airmen with pre-injury neuropsychiatric testing and chronic stable TBI symptoms, HBOT 1.5 resulted in resolution of symptoms as well as a return to the pre-injury values for testing. [20] In a randomized controlled trial of stable severe TBI treated with HBOT 1.5 Lin et al demonstrated improvement in the Glasgow Coma Scale. [21] Rockswold has demonstrated improvement in the Glasgow Coma Scale and reduced mortality in acute TBI patients undergoing HBOT with minimal risk. [22,23] HBOT 1.5 in this group of acute patients appears safe and does not produce oxygen toxicity. [24] Other individual trials also have demonstrated the efficacy of HBOT 1.5 for chronic stable TBI. [25] A 310 patient Chinese trial demonstrated improvement clinically, in neuropsychiatric testing, as well as in functional brain imaging after HBOT 1.5.[26] In a randomized controlled trial of 21 brain-injured adults, HBOT 1.5 resulted in improved neuropsychiatric testing for the treated group. [27]

Families of children with CP typically don't have deep pockets, but many professional football players do and so between my San Francisco and Sacramento hyperbaric practices football players have come to receive HBOT and it is my hope that their experience will bring the awareness of HBOT to families and mainstream medicine. We have embraced acupuncture as a treatment modality in this nation (it has only been used for 5,000 years in China and Japan). Why not HBOT?

It is interesting to note that more concussions were being reported in the National Football League (NFL) in the 2010 season. 154 concussions which occurred in practices or games were reported from the start of the preseason through the eighth week of the 2010 regular season. That is an increase of 21 percent over the 127 concussions during the same span in 2009, and a 34 percent jump from the 115 reported through the eighth week of the 2008 season. (Associated Press, Dec 13, 2010)

This either means better reporting is taking place or the game is getting more violent or some combination of the above. What hasn't changed is a lack of treatment. The lack of appropriate treatment for traumatic brain injury (TBI) and chronic traumatic encephalopathy (CTE) is not exclusive to the NFL by any means, but football players both young high school players and old retired NFL veterans are beginning to ask questions about Hyperbaric Oxygen Therapy (HBOT) and exploring its use as a therapeutic intervention to help them recover from their injuries.

George Visger (retired NFL) is just one example. The details of his personal story can be found on NPR [http://www.npr.org/templates/story/story.php?storyId= 114059228]. George is now in his early 50's, but was first hospitalized with a TBI resulting in loss of consciousness during a tackling drill playing Pop Warner football. Numerous minor concussions took place over the years, but he experienced his second major concussion during the first play for his NFL team (San Francisco 49ers) early in the first quarter and went through 25 to 30 smelling salts in order to finish the game. He had no recollection of participating in that game, but was sent back on the practice field the very next day.

Early in his second season (1981), he developed hydrocephalus, and underwent emergency shunt brain surgery. Four months after his team won Super Bowl XVI, his shunt failed, and he had back-to-back emergency brain surgeries and was given last rites.

By 1990 he had nine more shunt revisions. He was treated with HBOT 1.5 times 40 for 60 minutes per treatment (one treatment per day--100% oxygen). He was independently followed with neurocognitive evaluations and SPECT brain imaging by the Amen Clinic in California. The before and after SPECT Scans and a graph of George's improved neurocognitive scores can be viewed at: http://www.medicalgasresearch.com/content/1/1/17/abstract. But the bottom line was that he significantly improved in 5 out of 6 outcome measures (the 6th remained unchanged--Spatial Processing Speed).

This is not about football teams secretly having their own hyperbaric chambers to help deal with athletic injuries. This is not just about having HBOT available for front line troops at a MASH unit; although, that would be a excellent place for them. This is about openly using HBOT as standard medical care for any injury that can benefit from it, specifically head injuries and neurological conditions which this therapy can treat with positive results and without risk.

There are numerous citations referenced in this article. Because of space limitations these have been eliminated. If readers wish to have access to any reference, please email your request to Rick Rader, MD at Habctrmd@aol.com.

GLOSSARY OF TERMS HBOT Article on TBI

* "P values" = The p-value measures consistency between the results actually obtained in the trial and the "pure chance" explanation for those results.

* TBI/PTSD = Traumatic Brain Injury/Post Traumatic Stress Disorder

* "Atmospheres" = a unit of pressure. Scuba divers and others use the word atmosphere and "atm" in relation to pressures that are relative to mean atmospheric pressure at sea level (1.013 bar). For example, a partial pressure of oxygen is calibrated typically using air at sea level, so is expressed in units of atm.

* Decompression Sickness = Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurization

* Ischemic stroke = loss of oxygenated blood being delivered to the brain

* Encephalopathy = disorder or disease of the brain

* Global Anoxia = brain injury to the brain caused by lack of oxygen, not limited to any specific part of the brain.

* SPECT Brain Imaging = Single-photon emission computed tomography is a nuclear medicine imaging technique using gamma rays.

* Glascow Coma Scale = a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person

K Paul Stoller, MD is a Fellow of the American College of Hyperbaric Medicine, President of the International Hyperbaric Medical Association, Adjunct Assistant Professor at AT Still University (SOMA), and Medical Director of the New Hope Clinic in Santa Monica, the San Francisco Institute for Hyperbaric Medicine, the Hyperbaric Medical Center of New Mexico and the Hyperbaric Oxygen Clinic Sacramento. A UC President's Undergraduate Fellow in the Health Sciences, Dr. Stoller completed his medical education at UCLA and was board certified in Pediatrics for over two decades.
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Title Annotation:United States Military Section
Author:Stollar, Ken
Publication:The Exceptional Parent
Geographic Code:1USA
Date:Aug 1, 2011
Words:2142
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