Hyperbaric Oxygen for Brain Injury
James K. Wright, MD, Col, USAF (Ret)
Traumatic Brain Injuryin Active Duty and Veterans
• 300,000+ cases from OEF/OIF (19.5%)– RAND Report 2008
• 300,000+ have PTSD (18.5%)
• TBI makes PTSD more likely
• About 2/3 of PTSD have TBI also
• < ½ get “minimally adequate care”
Example of TBI impact assessment in NFL Player
• NFL football player with concussion
• Loss of about 2% of the fiber tracts in the region of the corpus callosum.
Area of Tissue change Fibers passing through areas
Enlarged Fiber Tract showing fibers from concussive event
Courtesy Dr. Walter Schneider, U Pittsburgh
1st 2 Airmen Treated for TBI
• 2 USAF Airmen• Previously healthy• No Hx head injury• IED 13 Jan 2008• In M915 14-ton truck• Concussive injuries (“bell
rung”)• No LOC• No Amnesia
5
Symptoms
• Immediate– Headache– Slight confusion– Assessed– Off line for 2-3 days
• Delayed – 3 weeks +– Irritability– Sleep disturbances– Headaches– Memory difficulties– Cognitive difficulties– Clumsy
• Threatened with job loss
6
Results of HBOT for TBI
7
0102030405060708090
100
Simple
Reacti
on Time
Procedural
Reacti
on Time
Code Substi
tution Learn
ing
Code Substi
tution Dela
yed
Mathem
atical
Processin
g
Matching t
o Sample
11-Nov-0721-J ul-0810-Oc t-0816-J an-09
Airman B
Airman C
Date of IED13 Jan 2008
Symptom resolution
• Headaches• Sleep disturbances• Fatigue• Irritability• Memory loss• Fine motor reactions• Cognitive function
Time
What HBOT is
• 100% oxygen under pressure
• 1.5 – 2/0 ATA for brain injury
• 40-80 1 hr treatments • 1-2 HBOT per day• Used for more than
100 years for brain injury
How it works - 5,769+* ways
• Upregulates growth factors
• Reduces edema• Promotes neural pathway
growth• Activates senescent
neurons• Increases neuronal ATP• Downregulates
inflammation• Reduces reperfusion
injury
*Rink C, Roy S, Khan M, Ananth P, Kuppusamy P, Sen CK, Khanna S. Oxygen-sensitive outcomes and gene expression in acute ischemic stroke. J Cereb Blood Flow Metab. 2010 Feb 10.
HBOT Indications1) Air or gas embolism2) Carbon monoxide poisoning3) Gas gangrene4) Traumatic ischemias – crush injury, compartment syndrome5) Decompression sickness6) Arterial insufficiencies7) Severe anemia8) Intracranial abscess9) Necrotizing soft tissue infections10) Refractory osteomyelitis11) Delayed radiation injury12) Compromised flaps and grafts13) Acute thermal burn injury14) Problem wounds15) Retinal ischemic disease
HBOT has been used for >100 years to treat brain injury
NBIRRNational Brain Injury rescue and Rehabilitation Project
• 1000 patients with mTBI
• 17+ centers• All receive HBOT• Early results
encouraging• 35 participants
treated (Mar 2011)
• All participants have improved
• Most improved in every measure
• Most improved substantially
• No participants worsened
• Results are durable
Results
• 1st 12 consecutive patients with TBI
• All received HBOT
• All improved in nearly every measure
• Results are % change in ANAM mood scores
% Change in Mood
-35
-25
-15
-5
5
15
25
35
Sle
ep
ine
ss
Vig
or
Re
stle
ssn
ess
De
pre
ssio
n
An
ge
r
Fa
tigu
e
An
xie
ty
Ha
pp
ine
ss
ANAM Results
• 1st 12 consecutive patients with TBI
• All received HBOT
• All improved in nearly every measure
• Results are % improvement in ANAM scores
% improvement in ANAM scores
0
10
20
30
40
50
60
Sim
ple
Rea
ctio
nT
ime
Cod
eS
ubst
itutio
nLe
arni
ng
Pro
cedu
ral
Rea
ctio
nT
ime
Mat
hem
atic
alP
roce
ssin
g
Mat
chin
g to
Sam
ple
Cod
eS
ubst
itutio
nD
elay
ed
Comparison to Pre-Injury Status
N=4
ANAM Scorespre-injury, post injury, post HBOT
100%
50%
0
Do HBOT recipients get back to normal?
Back to Normal Test (N=8)
0
20
40
60
80
100
Pre H
BOT Em
otion
al
Post H
BOT Em
otion
al
Pre H
BOT Phy
sical
Post H
BOT Phy
sical
Pre H
BOT Cog
nitive
Post H
BOT Cog
nitive
Pe
rce
nti
le
Avg time elapsed = 108
days
PHQ-9 Test
PHQ-9 Test Results
00.5
11.5
22.5
Little interest orpleasure indoing things
Feeling dow n,depressed, or
hopeless
Trouble fallingor stayingasleep, or
sleeping toomuch
Feeling tired orhaving little
energy
Poor appetite orovereating
Feeling badabout yourself -or that you are
a failure orhave let
yourself or yourfamily dow n
Troubleconcentrating
on things, suchas reading thenew spaper or
w atchingtelevision
Moving orspeaking soslow ly thatother peoplecould have
noticed? Or theopposite - being
so f idgety orrestless that
you have beenmoving arounda lot more than
Thoughts thatyou w ould bebetter off dead
or hurtingyourself insome w ay
test
sco
re
N = 8Avg HBOT = 44Avg elapsed time = 85 daysTotal score avg 13 → 3
PHQ-15 TestPHQ 15 Results (N = 16)
0
5
10
15
20
25
stom
ach p
ain
back
pai
n
extre
mity
-join
t pai
n
head
ache
s
ches
t pain
dizz
iness
faint
ing sp
ells
hear
t pal
pitat
ions
shor
tnes
s of b
reat
h
sexu
al p
robl
ems
bowel
prob
lems
naus
ea-in
diges
tion
tired
-low e
nerg
y
trouble
slee
ping
What we have learned
• Every patient with TBI treated with HBOT has improved
• Improvement is durable
• The earlier you treat, the better the result
• More severe TBI requires more HBOT
• HBOT reduces the need for medication
• PTSD associated with TBI (2/3 of military PTSD cases) improves with HBOT
Questions?