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

Casey Owens Video

• Casey Owens video

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

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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?