HBOT: A Way to Heal the Injured Brain?

When SCUBA divers ascend from the high atmospheric pressure of the depths, it’s important to come up slowly so their bodies adjust to the low pressure at the surface. If they ascend too quickly, they will become ill with the “bends,” or decompression sickness, and require some time in a hyperbaric oxygen (HBO) chamber receiving 100 percent oxygen under higher atmospheric pressure. Hyperbaric oxygen therapy (HBOT) has been found to also be helpful in a variety of other conditions, including crush injuries, acute carbon monoxide poisoning, and diabetic wounds.

HBOT is also used to treat brain injury from trauma or another cause such as stroke. While the number of people who have used HBOT for brain injury is unknown, its popularity is growing. However, insurance generally does not cover it nor has the FDA approved it for this use. Some older clinical studies do not demonstrate the effectiveness of HBOT with brain injury, but a growing number of more recent studies do.

One study, from 2009, demonstrated that the patients with severe brain injury who received higher levels of oxygen in an HBO chamber had a positive increase in brain metabolism when compared to the control group and the group who received “normobaric” treatment, or treatment with pressure equivalent to sea level (Rockswald & Rockswald, 2010).

A groundbreaking study of U.S. military veterans with blast-induced mild traumatic brain injury and PTSD, published in 2011, produced significant results. “Headaches, post-concussion symptoms, abnormal neurological exam findings, cognition, PTSD, depression suicidal ideation, quality of life and brain blood flow were significantly improved after a one month course of HBOT.” Six months later, the great majority of veterans in the study sustained their improvements.

Bruce Gottlieb, MD, medical director of Hyperbaric Services of the Palm Beaches, LLC, in Delray Beach, Fla., is an enthusiastic supporter of HBOT. He says HBOT “is one of the simplest therapies around, but there is a lot of confusion around it. Lots of people claim to provide HBO therapy, but many of them in reality do not.” It is crucial to have close medical supervision in an accredited facility, he says. It should not be done at home.

The basic guideline of his clinic, he says, is that “HBO is an adjunct therapy. It is not a primary therapy for brain injury. And it is not a panacea or a silver bullet. We stress that patients have to do other therapies — occupational, physical, speech, and even psychological — in conjunction with HBO.”

He likens HBOT to a catalyst, “like Miracle-Gro for your lawn. The soil has to be good for it to work.” And with brain injury, the other therapies improve the condition of the brain to make it more receptive to HBOT.

Treatment with HBOT

Patients receive either one or two daily HBO sessions, depending on the time they have available, and brain injury requires a minimum of 40 to 80 sessions of one or two hours each — and often many more, according to Gottlieb and Sarah Crane, director of research. Treatment is cumulative, with more improvement occurring with more sessions.

The cost of HBOT for brain injury varies among regions and the facilities where it is performed. According to Crane, the per-session fee across the country ranges from $500 to $1,500, which adds up quickly. However, most clinical studies do not charge fees to those enrolled in the studies. Hyperbaric Services of the Palm Beaches, one of about 500 HBOT centers in the U.S., is participating in a clinical trial of HBOT through the National Brain Injury Rescue and Rehabilitation (NBIRR) Clinical Trial. They are not charging fees to enrollees.

How does it work?

The brain uses oxygen at a “ferocious rate,” Gottlieb says, and can easily become starved. When a trauma occurs, the brain often swells, so the injured tissue does not receive enough oxygen. “So the area that needs the most oxygen gets the least,” he says. HBOT drives oxygen into the cerebrospinal fluid, which carries it to the brain and permits healing.

Inflammation is another damaging result of a brain injury, acting much like a fire in its destructive power. But HBOT can put out that fire by sending 100 percent oxygen to the injured areas, and slowly the areas heal.

Gottlieb says there are no side effects or ill effects from HBOT, although some people experience increased pressure in the ear, similar to what happens in a plane. Some people should not do HBOT, including those with severe lung disease such as emphysema, uncontrolled seizure activity, or severe inner ear pain. Since the person undergoing treatment lies down and music can be piped in, HBOT can be very relaxing.

Clinical studies of HBOT will continue for some time. Many people with brain injury and their families hope it will someday be a proven therapy covered by insurance.

Two HBOT Success Storis

Bryan Gansner

A blast from an improvised explosive device blew up the vehicle carrying Army SSgt. Bryan Gansner in Iraq in 2006. While he was originally diagnosed with a mild brain injury, later scans showed it to be moderate. He also had PTSD.

Cheryl Gansner recalls that her husband had “behavioral problems, was very angry and forgetful. He was not performing well at work. He was kind of off, not himself.” For two years after he came home, he slept alone in the basement and remained removed and isolated. By 2009, “he hit rock bottom,” she says. The couple was close to divorce, and Bryan wanted to quit his job, move to his parents’ home, and do nothing. “He didn’t want kids because he thought he wouldn’t be a good enough father,” she says.

But a friend whose husband had undergone HBOT for brain injury with good results recommended it for Bryan. He was able to enroll in a clinical trial studying HBOT for brain injury in veterans, in New Orleans, and began treatment with 40 sessions in October 2009. When the study was over, he did 40 more. And Cheryl, program director for Hearts of Valor, a network of people caring for wounded, ill or injured service members, created and maintained by Operation Homefront, saw a huge difference in her husband.

“His depression and PTSD are way down,” she says. “His IQ rose six points, his anxiety is down considerably, his auditory memory and verbal skills are much improved.” His sleep also improved dramatically, and his medication dosages have been lowered. The Gansners are now awaiting the birth of their first child.

“I have my husband back,” says Cheryl. “We’re appreciative of the gains he made.”

Johnny Torres

Two weeks before his 21st birthday, Johnny Torres was struck by a vehicle near his home in Tucson. On active duty with the Army, he suffered a diffuse axonal injury to his brain, along with bleeding in his corpus callosum, leaving him in a coma for two weeks, and severely debilitated after that. He was bedridden, unable to swallow, talk, walk, or function independently in any way. His cognition was severely affected. He spent time at a local rehab hospital, then 90 days at the VA hospital in Palo Alto, Calif., and then another 90 at the Tucson VA hospital, says his mother, Diana Torres. Then we brought him home.”

Johnny required round-the-clock care, provided by Diana and paid caregivers. “He was combative, he would hit me and spit on me. Sometimes he would get me in a headlock and my husband would have to help me out,” she says. “I would pass out on the couch, I was so exhausted.”

Diana heard about HBOT but originally declined to put Johnny into treatment because of the high cost. But she later spoke with Dr. Carol Henricks, a Tucson neurologist who does HBOT and who Diana calls “an angel,” and decided the cost was worth it. He has now had nearly 400 sessions. Diana says her son is vastly improved.

“He is calmer and less combative,” she explains. “He eats everything, no longer drools. His cognition is good — he can watch TV and understand it. He’s started talking, and now says a new word nearly every day.” His pre-injury strength is returning, and he can push himself up and wrestle with his dad.

How many more treatments will he have? “I’m not going to stop,” says Diana. “I see miracles happening here.”

Reference:

Rockswald, SB, Rockswald, GL, Zaun, DA, Zhang, X, Cerra, CE, Bergman, TA, Liu, J (2010). A prospective randomized clinical trial to compare the effect of hyperbaric to normobarck hyperoxia on cerebral metabolism, intracranial pressure, and oxygen toxicity in severe traumatic brain injury. Journal of Neurosurgery 112(5): 1080-1094.