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van Ierssel JJ, Galea O, Holte K, Luszawski C, Jenkins E, O'Neil J, Emery CA, Mannix R, Schneider K, Yeates KO, Zemek R. How completely are randomized controlled trials of non-pharmacological interventions following concussion reported? A systematic review. JOURNAL OF SPORT AND HEALTH SCIENCE 2024; 13:537-547. [PMID: 37619783 PMCID: PMC11184319 DOI: 10.1016/j.jshs.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/20/2023] [Accepted: 07/12/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE The study aimed to examine the reporting completeness of randomized controlled trials (RCTs) of non-pharmacological interventions following concussion. METHODS We searched MEDLINE, Embase, PsycInfo, CINAHL, and Web of Science up to May 2022. Two reviewers independently screened studies and assessed reporting completeness using the Template for Intervention Description and Replication (TIDieR), Consensus on Exercise Reporting Template (CERT), and international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) checklists. Additional information was sought my study authors where reporting was incomplete. Risk of bias (ROB) was assessed with the Cochrane ROB-2 Tool. RCTs examining non-pharmacological interventions following concussion. RESULTS We included 89 RCTs (n = 53 high ROB) examining 11 different interventions for concussion: sub-symptom threshold aerobic exercise, cervicovestibular therapy, physical/cognitive rest, vision therapy, education, psychotherapy, hyperbaric oxygen therapy, transcranial magnetic stimulation, blue light therapy, osteopathic manipulation, and head/neck cooling. Median scores were: TIDieR 9/12 (75%; interquartile range (IQR) = 5; range: 5-12), CERT 17/19 (89%; IQR = 2; range: 10-19), and i-CONTENT 6/7 (86%; IQR = 1; range: 5-7). Percentage of studies completely reporting all items was TIDieR 35% (31/89), CERT 24% (5/21), and i-CONTENT 10% (2/21). Studies were more completely reported after publication of TIDieR (t87 = 2.08; p = 0.04) and CERT (t19 = 2.72; p = 0.01). Reporting completeness was not strongly associated with journal impact factor (TIDieR: rs = 0.27; p = 0.01; CERT: rs = -0.44; p = 0.06; i-CONTENT: rs = -0.17; p = 0.48) or ROB (TIDieR: rs = 0.11; p = 0.31; CERT: rs = 0.04; p = 0.86; i-CONTENT: rs = 0.12; p = 0.60). CONCLUSION RCTs of non-pharmacological interventions following concussion demonstrate moderate to good reporting completeness, but are often missing key components, particularly modifications, motivational strategies, and qualified supervisor. Reporting completeness improved after TIDieR and CERT publication, but publication in highly cited journals and low ROB do not guarantee reporting completeness.
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Affiliation(s)
| | - Olivia Galea
- The Centre for Health, Activity and Rehabilitation Research, University of Otago, Dunedin 9016, New Zealand
| | - Kirsten Holte
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute; University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Caroline Luszawski
- Alberta Children's Hospital Research Institute; University of Calgary, Calgary, AB T2N 1N4, Canada; Department of Psychology, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Elizabeth Jenkins
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Jennifer O'Neil
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, ON K1H 8M5, Canada; Bruyère Research Institute, Ottawa, ON K1N 5C8, Canada
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute; University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Rebekah Mannix
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Kathryn Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute; University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute; University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada; Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
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Andrews SR, Harch PG. Systematic review and dosage analysis: hyperbaric oxygen therapy efficacy in the treatment of posttraumatic stress disorder. Front Neurol 2024; 15:1360311. [PMID: 38882688 PMCID: PMC11179433 DOI: 10.3389/fneur.2024.1360311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 05/08/2024] [Indexed: 06/18/2024] Open
Abstract
Background Studies of hyperbaric oxygen therapy (HBOT) treatment of mild traumatic brain injury persistent postconcussion syndrome in military and civilian subjects have shown simultaneous improvement in posttraumatic stress disorder (PTSD) or PTSD symptoms, suggesting that HBOT may be an effective treatment for PTSD. This is a systematic review and dosage analysis of HBOT treatment of patients with PTSD symptoms. Methods PubMed, CINAHL, and the Cochrane Systematic Review Database were searched from September 18 to November 23, 2023, for all adult clinical studies published in English on HBOT and PTSD. Randomized trials and studies with symptomatic outcomes were selected for final analysis and analyzed according to the dose of oxygen and barometric pressure on symptom outcomes. Outcome assessment was for statistically significant change and Reliable Change or Clinically Significant Change according to the National Center for PTSD Guidelines. Methodologic quality and bias were determined with the PEDro Scale. Results Eight studies were included, all with < 75 subjects/study, total 393 subjects: seven randomized trials and one imaging case-controlled study. Six studies were on military subjects, one on civilian and military subjects, and one on civilians. Subjects were 3-450 months post trauma. Statistically significant symptomatic improvements, as well as Reliable Change or Clinically Significant changes, were achieved for patients treated with 40-60 HBOTS over a wide range of pressures from 1.3 to 2.0 ATA. There was a linear dose-response relationship for increased symptomatic improvement with increasing cumulative oxygen dose from 1002 to 11,400 atmosphere-minutes of oxygen. The greater symptomatic response was accompanied by a greater and severe reversible exacerbation of emotional symptoms at the highest oxygen doses in 30-39% of subjects. Other side effects were transient and minor. In three studies the symptomatic improvements were associated with functional and anatomic brain imaging changes. All 7 randomized trials were found to be of good-highest quality by PEDro scale scoring. Discussion In multiple randomized and randomized controlled clinical trials HBOT demonstrated statistically significant symptomatic improvements, Reliable Changes, or Clinically Significant Changes in patients with PTSD symptoms or PTSD over a wide range of pressure and oxygen doses. The highest doses were associated with a severe reversible exacerbation of emotional symptoms in 30-39% of subjects. Symptomatic improvements were supported by correlative functional and microstructural imaging changes in PTSD-affected brain regions. The imaging findings and hyperbaric oxygen therapy effects indicate that PTSD can no longer be considered strictly a psychiatric disease.
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Affiliation(s)
- Susan R Andrews
- Neuropsychological Services for Children and Adults, Metairie, LA, United States
| | - Paul G Harch
- Section of Emergency and Hyperbaric Medicine, Department of Medicine, LSU Health Sciences Center, New Orleans, LA, United States
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Harch PG, Rhodes S. Acute and chronic central nervous system oxidative stress/toxicity during hyperbaric oxygen treatment of subacute and chronic neurological conditions. Front Neurol 2024; 15:1341562. [PMID: 38500807 PMCID: PMC10946424 DOI: 10.3389/fneur.2024.1341562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/10/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction Oxygen toxicity has been defined as acute central nervous system (CNS), acute pulmonary, and chronic pulmonary oxygen toxicity. This study identifies acute and chronic CNS oxygen toxicity under 2.0 atmospheres absolute (ATA) pressure of oxygen. Methods: The authors' medical records from September 29, 1989 to January 20, 2023 and correspondence to the authors (9/1994 to 1/20.2023) from patients with signs and/or symptoms historically identified as acute CNS oxygen toxicity and those with neurological deterioration receiving hyperbaric oxygen for neurological conditions were reviewed. Acute cases were those occurring with ≤5 HBOTs and chronic cases >5 HBOTs. Chronic cases were separated into those at 1.5 ATA, > 1.5 ATA, or < 1.5 ATA oxygen. Cumulative dose of oxygen in atmosphere-hours (AHs) was calculated at symptom onset. Results Seven acute cases, average 4.0 ± 2.7 AHs, and 52 chronic cases were identified: 31 at 1.5 ATA (average 116 ± 106 AHs), 12 at >1.5 ATA (103 ± 74 AHs), and 9 at <1.5 ATA (114 ± 116 AHs). Second episodes occurred at 81 ± 55, 67 ± 49, and 22 ± 17 AHs, and three or more episodes at 25 ± 18, 83 ± 7.5, and 5.4 ± 6.0 AHs, respectively. Most cases were reversible. There was no difference between adults and children (p = 0.72). Acute intervention in cases (<3 months) was more sensitive than delayed intervention (21.1 ± 8.8 vs. 123 ± 102 AHs, p = 0.035). Outside sources reported one acute and two chronic exposure deaths and one patient institutionalized due to chronic oxygen toxicity. A withdrawal syndrome was also identified. Conclusion Hyperbaric oxygen therapy-generated acute and chronic cases of CNS oxygen toxicity in chronic neurological conditions were identified at <2.0 ATA. Chronic CNS oxygen toxicity is idiosyncratic, unpredictable, and occurred at an average threshold of 103-116 AHs with wide variability. There was no difference between adults and children, but subacute cases were more sensitive than chronic intervention cases. When identified early it was reversible and an important aid in proper dosing of HBOT. If ignored permanent morbidity and mortality resulted with continued HBOT.
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Affiliation(s)
- Paul G. Harch
- Family Physician Center, Marrero, LA, United States
- Department of Emergency Medicine, University Medical Center, New Orleans, LA, United States
- Section of Emergency Medicine, Department of Medicine, Louisiana State University, New Orleans, LA, United States
| | - Stacey Rhodes
- Department of Emergency Medicine, University Medical Center, New Orleans, LA, United States
- Section of Emergency Medicine, Department of Medicine, Louisiana State University, New Orleans, LA, United States
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Sunshine MD, Bindi VE, Nguyen BL, Doerr V, Boeno FP, Chandran V, Smuder AJ, Fuller DD. Oxygen therapy attenuates neuroinflammation after spinal cord injury. J Neuroinflammation 2023; 20:303. [PMID: 38110993 PMCID: PMC10729514 DOI: 10.1186/s12974-023-02985-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023] Open
Abstract
Acute hyperbaric O2 (HBO) therapy after spinal cord injury (SCI) can reduce inflammation and increase neuronal survival. To our knowledge, it is unknown if these benefits of HBO require hyperbaric vs. normobaric hyperoxia. We used a C4 lateralized contusion SCI in adult male and female rats to test the hypothesis that the combination of hyperbaria and 100% O2 (i.e. HBO) more effectively mitigates spinal inflammation and neuronal loss, and enhances respiratory recovery, as compared to normobaric 100% O2. Experimental groups included spinal intact, SCI no O2 therapy, and SCI + 100% O2 delivered at normobaric pressure (1 atmosphere, ATA), or at 2- or 3 ATA. O2 treatments lasted 1-h, commenced within 2-h of SCI, and were repeated for 10 days. The spinal inflammatory response was assessed with transcriptomics (RNAseq) and immunohistochemistry. Gene co-expression network analysis showed that the strong inflammatory response to SCI was dramatically diminished by both hyper- and normobaric O2 therapy. Similarly, both HBO and normobaric O2 treatments reduced the prevalence of immunohistological markers for astrocytes (glial fibrillary acidic protein) and microglia (ionized calcium binding adaptor molecule) in the injured spinal cord. However, HBO treatment also had unique impacts not detected in the normobaric group including upregulation of an anti-inflammatory cytokine (interleukin-4) in the plasma, and larger inspiratory tidal volumes at 10-days (whole body-plethysmography measurements). We conclude that normobaric O2 treatment can reduce the spinal inflammatory response after SCI, but pressured O2 (i.e., HBO) provides further benefit.
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Affiliation(s)
- Michael D Sunshine
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Victoria E Bindi
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Branden L Nguyen
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Vivian Doerr
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Franccesco P Boeno
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | | | - Ashley J Smuder
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - David D Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.
- McKnight Brain Institute, University of Florida, Gainesville, FL, USA.
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Doenyas-Barak K, Kutz I, Lang E, Merzbach R, Lev Wiesel R, Boussi-Gross R, Efrati S. The use of hyperbaric oxygen for veterans with PTSD: basic physiology and current available clinical data. Front Neurosci 2023; 17:1259473. [PMID: 38027524 PMCID: PMC10630921 DOI: 10.3389/fnins.2023.1259473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) affects up to 30% of veterans returning from the combat zone. Unfortunately, a substantial proportion of them do not remit with the current available treatments and thus continue to experience long-term social, behavioral, and occupational dysfunction. Accumulating data implies that the long-standing unremitting symptoms are related to changes in brain activity and structure, mainly disruption in the frontolimbic circuit. Hence, repair of brain structure and restoration of function could be a potential aim of effective treatment. Hyperbaric oxygen therapy (HBOT) has been effective in treating disruptions of brain structure and functions such as stroke, traumatic brain injury, and fibromyalgia even years after the acute insult. These favorable HBOT brain effects may be related to recent protocols that emphasize frequent fluctuations in oxygen concentrations, which in turn contribute to gene expression alterations and metabolic changes that induce neuronal stem cell proliferation, mitochondrial multiplication, angiogenesis, and regulation of the inflammatory cascade. Recently, clinical findings have also demonstrated the beneficial effect of HBOT on veterans with treatment-resistant PTSD. Moderation of intrusive symptoms, avoidance, mood and cognitive symptoms, and hyperarousal were correlated with improved brain function and with diffusion tensor imaging-defined structural changes. This article reviews the current data on the regenerative biological effects of HBOT, and the ongoing research of its use for veterans with PTSD.
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Affiliation(s)
- Keren Doenyas-Barak
- Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Kutz
- Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin, Israel
| | - Erez Lang
- Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Merzbach
- Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin, Israel
- The Louis and Gabi Weisfeld School of Social Work, Bar-Ilan University, Ramat Gan, Israel
| | - Rachel Lev Wiesel
- Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin, Israel
- The Emili Sagol Creative Arts Therapies Research Center, University of Haifa, Haifa, Israel
| | - Rahav Boussi-Gross
- Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin, Israel
| | - Shai Efrati
- Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Schimmel S, El Sayed B, Lockard G, Gordon J, Young I, D’Egidio F, Lee JY, Rodriguez T, Borlongan CV. Identifying the Target Traumatic Brain Injury Population for Hyperbaric Oxygen Therapy. Int J Mol Sci 2023; 24:14612. [PMID: 37834059 PMCID: PMC10572450 DOI: 10.3390/ijms241914612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Traumatic brain injury (TBI) results from direct penetrating and indirect non-penetrating forces that alters brain functions, affecting millions of individuals annually. Primary injury following TBI is exacerbated by secondary brain injury; foremost is the deleterious inflammatory response. One therapeutic intervention being increasingly explored for TBI is hyperbaric oxygen therapy (HBOT), which is already approved clinically for treating open wounds. HBOT consists of 100% oxygen administration, usually between 1.5 and 3 atm and has been found to increase brain oxygenation levels after hypoxia in addition to decreasing levels of inflammation, apoptosis, intracranial pressure, and edema, reducing subsequent secondary injury. The following review examines recent preclinical and clinical studies on HBOT in the context of TBI with a focus on contributing mechanisms and clinical potential. Several preclinical studies have identified pathways, such as TLR4/NF-kB, that are affected by HBOT and contribute to its therapeutic effect. Thus far, the mechanisms mediating HBOT treatment have yet to be fully elucidated and are of interest to researchers. Nonetheless, multiple clinical studies presented in this review have examined the safety of HBOT and demonstrated the improved neurological function of TBI patients after HBOT, deeming it a promising avenue for treatment.
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Affiliation(s)
- Samantha Schimmel
- Morsani College of Medicine, University of South Florida, 560 Channelside Dr., Tampa, FL 33602, USA; (S.S.); (B.E.S.); (G.L.); (J.G.)
| | - Bassel El Sayed
- Morsani College of Medicine, University of South Florida, 560 Channelside Dr., Tampa, FL 33602, USA; (S.S.); (B.E.S.); (G.L.); (J.G.)
| | - Gavin Lockard
- Morsani College of Medicine, University of South Florida, 560 Channelside Dr., Tampa, FL 33602, USA; (S.S.); (B.E.S.); (G.L.); (J.G.)
| | - Jonah Gordon
- Morsani College of Medicine, University of South Florida, 560 Channelside Dr., Tampa, FL 33602, USA; (S.S.); (B.E.S.); (G.L.); (J.G.)
| | | | - Francesco D’Egidio
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA; (F.D.); (J.Y.L.)
| | - Jea Young Lee
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA; (F.D.); (J.Y.L.)
| | - Thomas Rodriguez
- School of Medicine, Loma Linda University, 11175 Campus St., Loma Linda, CA 92350, USA;
| | - Cesar V. Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA; (F.D.); (J.Y.L.)
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Wright B, Guilliod R, Thakur B, Kundig C, Morales J, Tessler J, Berry J, Zhang R, Bell KR, Pinto SM. Hyperbaric Oxygen Therapy versus placebo for post-concussion syndrome (HOT-POCS): A randomized, double-blinded controlled pilot study. Contemp Clin Trials Commun 2023; 34:101176. [PMID: 37416626 PMCID: PMC10320499 DOI: 10.1016/j.conctc.2023.101176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023] Open
Abstract
Post-Concussion Syndrome (PCS) refers to the persistence of physical, cognitive, and emotional symptoms following mild traumatic brain injury (mTBI)/concussion, occurring in roughly 15-30% of individuals. Hyperbaric oxygen therapy (HBOT) has been suggested as a potential treatment for PCS; however, the evidence to date is mixed due to inconsistencies in the treatment protocol and focus on veterans with combat-related injuries, which may not be generalizable to the general population. The goal of Hyperbaric Oxygen Therapy for Post-Concussion Syndrome (HOT-POCS) is to assess the efficacy and safety of HBOT for the treatment of PCS in the civilian population. This randomized, controlled pilot study will be using a standardized HBOT protocol (20 sessions of 100% O2 at 2.0 atm absolute [ATA]) compared with a true placebo gas system that mimics the oxygen composition at room air (20 sessions of 10.5% O2 and 89.5% nitrogen at 2.0 ATA) in a cohort of 100 adults with persistent post-concussive symptoms 3-12 months following injury. Change in symptoms on the Rivermead Post-concussion Questionnaire (RPQ) will be the primary outcome of interest. Secondary outcomes include the rate of adverse events, change in the quality of life, and change in cognitive function. Exploratory outcome measures will include changes in physical function and changes in cerebral brain perfusion and oxygen metabolism on MRI brain imaging. Overall, the HOT-POCS study will compare the efficacy of a standardized HBOT treatment protocol against a true placebo gas for the treatment of PCS within 12 months after injury.
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Affiliation(s)
- Brittany Wright
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Renie Guilliod
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bhaskar Thakur
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Charles Kundig
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jill Morales
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joseph Tessler
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Berry
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rong Zhang
- Departments of Neurology and Internal Medicine, University of Texas Southwestern Medical Center, Director of Cerebrovascular Laboratory, Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA
| | - Kathleen R. Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shanti M. Pinto
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Doenyas-Barak K, Kutz I, Levi G, Lang E, Beberashvili I, Efrati S. Hyperbaric Oxygen Therapy for Veterans With Treatment-resistant PTSD: A Longitudinal Follow-up Study. Mil Med 2023; 188:e2227-e2233. [PMID: 36433746 DOI: 10.1093/milmed/usac360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION PTSD is common among veteran combatants. PTSD is characterized by brain changes, for which available treatments have shown limited effect. In a short-term study, we showed that hyperbaric oxygen therapy (HBOT) induced neuroplasticity and improved clinical symptoms of veterans with treatment-resistant PTSD. Here, we evaluated the long-term clinical symptoms of the participants of that study. MATERIALS AND METHODS Veterans from our short-term study were recruited 1 or more years after completing HBOT. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and self-reported questionnaires were administered at a single site visit. Changes in clinical scores between long-term, short-term, and pretreatment evaluations were analyzed. RESULTS Of the 28 participants who received HBOT during or following the short-term study, 22 agreed to participate in the current study. At a mean of 704 ± 230 days after completing the HBOT course, the mean CAPS-5 score (26.6 ± 14.4) was significantly better (lower) than at the pre-HBOT evaluation (47.5 ± 13.1, P < .001) and not statistically different from the short-term evaluation (28.6 ± 16.7, P = .745). However, for the CAPS-5 subcategory D (cognition and mood symptoms), the mean score was significantly better (lower) at long-term than at short-term evaluation (7.6 ± 5.1 vs. 10.0 ± 6.0, P < .001). At the long-term compared to the pretreatment evaluation, higher proportions of the participants were living with life partners (10 (46%) vs. 17 (77%), P = .011) and were working (9 (41%) vs. 16 (73%), P = .033). Decreases were observed between pretreatment and the long-term follow-up, in the number of benzodiazepine users (from 10 (46%) to 4 (18%), P = .07) and in the median (range) cannabis daily dose (from 40.0 g (0-50) to 22.5 g (0-30), P = .046). CONCLUSIONS The beneficial clinical effects of HBOT are persistent and were not attenuated at long-term follow-up of about 2 years after completion of HBOT. Additional long-term effects of the treatment were observed in social function and in decreased medication use.
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Affiliation(s)
- Keren Doenyas-Barak
- The Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin 70300, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Ilan Kutz
- The Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin 70300, Israel
| | - Gabriela Levi
- The Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin 70300, Israel
| | - Erez Lang
- The Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin 70300, Israel
| | - Ilia Beberashvili
- The Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin 70300, Israel
- Department of Nephrology, Shamir Medical Center, Zerifin 70300, Israel
| | - Shai Efrati
- The Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center, Zerifin 70300, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv 69978, Israel
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A Systematic Review of Treatments of Post-Concussion Symptoms. J Clin Med 2022; 11:jcm11206224. [PMID: 36294545 PMCID: PMC9604759 DOI: 10.3390/jcm11206224] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/01/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022] Open
Abstract
Approximately 10−20% of patients who have sustained a mild Traumatic Brain Injury (mTBI) show persistent post-concussion symptoms (PCS). This review aims to summarize the level of evidence concerning interventions for PCS. Following the PRISMA guidelines, we conducted a systematic review regarding interventions for PCS post-mTBI until August 2021 using the Medline, Cochrane, and Embase databases. Inclusion criteria were the following: (1) intervention focusing on PCS after mTBI, (2) presence of a control group, and (3) adult patients (≥18 y.o). Quality assessment was determined using the Incog recommendation level, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool. We first selected 104 full-text articles. Finally, 55 studies were retained, including 35 that obtained the highest level of evidence. The risk of bias was high in 22 out of 55 studies. Cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PCS. However, there is limited evidence of the beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy, and headache management using repetitive transcranial magnetic stimulation seem effective regarding somatic complaints and sleep disorders. The preventive effect of early (<3 months) interventions remains up for debate. Despite its limitations, the results of the present review should encourage clinicians to propose a tailored treatment to patients according to the type and severity of PCS and could encourage further research with larger groups.
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Hadanny A, Catalogna M, Yaniv S, Stolar O, Rothstein L, Shabi A, Suzin G, Sasson E, Lang E, Finci S, Polak N, Fishlev G, Harpaz RT, Adler M, Goldman RE, Zemel Y, Bechor Y, Efrati S. Hyperbaric oxygen therapy in children with post-concussion syndrome improves cognitive and behavioral function: a randomized controlled trial. Sci Rep 2022; 12:15233. [PMID: 36151105 PMCID: PMC9508089 DOI: 10.1038/s41598-022-19395-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Persistent post-concussion syndrome (PPCS) is a common and significant morbidity among children following traumatic brain injury (TBI) and the evidence for effective PPCS treatments remains limited. Recent studies have shown the beneficial effects of hyperbaric oxygen therapy (HBOT) in PPCS adult patients. This randomized, sham-control, double blind trial evaluated the effect of hyperbaric oxygen therapy (HBOT) on children (age 8–15) suffering from PPCS from mild-moderate TBI events six months to 10 years prior. Twenty-five children were randomized to receive 60 daily sessions of HBOT (n = 15) or sham (n = 10) treatments. Following HBOT, there was a significant increase in cognitive function including the general cognitive score (d = 0.598, p = 0.01), memory (d = 0.480, p = 0.02), executive function (d = 0.739, p = 0.003), PPCS symptoms including emotional score (p = 0.04, d = – 0.676), behavioral symptoms including hyperactivity (d = 0.244, p = 0.03), global executive composite score (d = 0.528, p = 0.001), planning/organizing score (d = 1.09, p = 0.007). Clinical outcomes correlated with significant improvements in brain MRI microstructural changes in the insula, supramarginal, lingual, inferior frontal and fusiform gyri. The study suggests that HBOT improves both cognitive and behavioral function, PPCS symptoms, and quality of life in pediatric PPCS patients at the chronic stage, even years after injury. Additional data is needed to optimize the protocol and to characterize the children who can benefit the most.
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Affiliation(s)
- Amir Hadanny
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel. .,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Merav Catalogna
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Slava Yaniv
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Orit Stolar
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Autism Center, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Lynn Rothstein
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Adi Shabi
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Gil Suzin
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Efrat Sasson
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Erez Lang
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shachar Finci
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nir Polak
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gregory Fishlev
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ruth Tock Harpaz
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Moran Adler
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Ron-El Goldman
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yonatan Zemel
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yair Bechor
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Shai Efrati
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
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11
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Harch PG. Systematic Review and Dosage Analysis: Hyperbaric Oxygen Therapy Efficacy in Mild Traumatic Brain Injury Persistent Postconcussion Syndrome. Front Neurol 2022; 13:815056. [PMID: 35370898 PMCID: PMC8968958 DOI: 10.3389/fneur.2022.815056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Mild traumatic brain injury results in over 15% of patients progressing to Persistent Postconcussion Syndrome, a condition with significant consequences and limited treatment options. Hyperbaric oxygen therapy has been applied to Persistent Postconcussion Syndrome with conflicting results based on its historical understanding/definition as a disease-specific therapy. This is a systematic review of the evidence for hyperbaric oxygen therapy (HBOT) in Persistent Postconcussion Syndrome using a dose-analysis that is based on the scientific definition of hyperbaric oxygen therapy as a dual-component drug composed of increased barometric pressure and hyperoxia. Methods In this review, PubMed, CINAHL, and the Cochrane Systematic Review Database were searched from August 8–22, 2021 for all adult clinical studies published in English on hyperbaric oxygen therapy in mild traumatic brain injury Persistent Postconcussion Syndrome (symptoms present at least 3 months). Randomized trials and studies with symptomatic and/or cognitive outcomes were selected for final analysis. Randomized trials included those with no-treatment control groups or control groups defined by either the historical or scientific definition. Studies were analyzed according to the dose of oxygen and barometric pressure and classified as Levels 1–5 based on significant immediate post-treatment symptoms or cognitive outcomes compared to control groups. Levels of evidence classifications were made according to the Centre for Evidence-Based Medicine and a practice recommendation according to the American Society of Plastic Surgeons. Methodologic quality and bias were assessed according to the PEDro Scale. Results Eleven studies were included: six randomized trials, one case-controlled study, one case series, and three case reports. Whether analyzed by oxygen, pressure, or composite oxygen and pressure dose of hyperbaric therapy statistically significant symptomatic and cognitive improvements or cognitive improvements alone were achieved for patients treated with 40 HBOTS at 1.5 atmospheres absolute (ATA) (four randomized trials). Symptoms were also improved with 30 treatments at 1.3 ATA air (one study), positive and negative results were obtained at 1.2 ATA air (one positive and one negative study), and negative results in one study at 2.4 ATA oxygen. All studies involved <75 subjects/study. Minimal bias was present in four randomized trials and greater bias in 2. Conclusion In multiple randomized and randomized controlled studies HBOT at 1.5 ATA oxygen demonstrated statistically significant symptomatic and cognitive or cognitive improvements alone in patients with mild traumatic brain injury Persistent Postconcussion Syndrome. Positive and negative results occurred at lower and higher doses of oxygen and pressure. Increased pressure within a narrow range appears to be the more important effect than increased oxygen which is effective over a broad range. Improvements were greater when patients had comorbid Post Traumatic Stress Disorder. Despite small sample sizes, the 1.5 ATA HBOT studies meet the Centre for Evidence-Based Medicine Level 1 criteria and an American Society of Plastic Surgeons Class A Recommendation for HBOT treatment of mild traumatic brain injury persistent postconcussion syndrome.
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12
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Hyperbaric oxygen therapy improves symptoms, brain's microstructure and functionality in veterans with treatment resistant post-traumatic stress disorder: A prospective, randomized, controlled trial. PLoS One 2022; 17:e0264161. [PMID: 35192645 PMCID: PMC8863239 DOI: 10.1371/journal.pone.0264161] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/29/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Post-traumatic stress disorder (PTSD) is characterized by changes in both brain activity and microstructural integrity. Cumulative evidence demonstrates that hyperbaric oxygen therapy (HBOT) induces neuroplasticity and case-series studies indicate its potentially positive effects on PTSD. The aim of the study was to evaluate HBOT’s effect in veterans with treatment resistant PTSD. Methods Veterans with treatment resistant PTSD were 1:1 randomized to HBOT or control groups. All other brain pathologies served as exclusion criteria. Outcome measures included clinician-administered PTSD scale-V (CAPS-V) questionnaires, brief symptom inventory (BSI), BECK depression inventory (BDI), brain microstructural integrity evaluated by MRI diffuse tensor imaging sequence (DTI), and brain function was evaluated by an n-back task using functional MRI (fMRI). The treatment group underwent sixty daily hyperbaric sessions. No interventions were performed in the control group. Results Thirty-five veterans were randomized to HBOT (N = 18) or control (n = 17) and 29 completed the protocol. Following HBOT, there was a significant improvement in CAPS-V scores and no change in the control (F = 30.57, P<0.0001, Net effect size = 1.64). Significant improvements were also demonstrated in BSI and BDI scores (F = 5.72, P = 0.024 Net effect size = 0.89, and F = 7.65, P = 0.01, Net effect size = 1.03). Improved brain activity was seen in fMRI in the left dorsolateral prefrontal, middle temporal gyri, both thalami, left hippocampus and left insula. The DTI showed significant increases in fractional anisotropy in the fronto-limbic white-matter, genu of the corpus callosum and fornix. Conclusions HBOT improved symptoms, brain microstructure and functionality in veterans with treatment resistant PTSD.
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13
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Marcinkowska AB, Mankowska ND, Kot J, Winklewski PJ. Impact of Hyperbaric Oxygen Therapy on Cognitive Functions: a Systematic Review. Neuropsychol Rev 2022; 32:99-126. [PMID: 33847854 PMCID: PMC8888529 DOI: 10.1007/s11065-021-09500-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 03/07/2021] [Indexed: 12/13/2022]
Abstract
Hyperbaric oxygen therapy (HBOT) is a modality of treatment in which patients inhale 100% oxygen inside a hyperbaric chamber pressurised to greater than 1 atmosphere. The aim of this review is to discuss neuropsychological findings in various neurological disorders treated with HBOT and to open new perspectives for therapeutic improvement. A literature search was conducted in the MEDLINE (via PubMed) database from the inception up 10 May 2020. Eligibility criteria included original articles published in English. Case studies were excluded. Full-text articles were obtained from the selected studies and were reviewed on the following inclusion criteria (1) performed cognitive processes assessment (2) performed HBOT with described protocol. Two neuropsychologists independently reviewed titles, abstracts, full texts and extracted data. The initial search retrieved 1024 articles, and a total of 42 studies were finally included after applying inclusion and exclusion criteria. The search yielded controversial results with regard to the efficiency of HBOT in various neurological conditions with cognitive disturbance outcome. To the best of our knowledge this is the first state-of-the art, systematic review in the field. More objective and precise neuropsychological assessment methods are needed to exact evaluation of the efficacy of HBOT for neuropsychological deficits. Future studies should widen the assessment of HBOT effects on different cognitive domains because most of the existing studies have focussed on a single process. Finally, there is a need for further longitudinal studies.
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Affiliation(s)
- Anna B Marcinkowska
- Applied Cognitive Neuroscience Lab, Department of Human Physiology, Medical University of Gdańsk, Tuwima Str. 15 80-210, Gdańsk, Poland.
- 2nd Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland.
| | - Natalia D Mankowska
- Applied Cognitive Neuroscience Lab, Department of Human Physiology, Medical University of Gdańsk, Tuwima Str. 15 80-210, Gdańsk, Poland
| | - Jacek Kot
- National Centre for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine in Gdynia, Medical University of Gdansk, Gdańsk, Poland
| | - Pawel J Winklewski
- Applied Cognitive Neuroscience Lab, Department of Human Physiology, Medical University of Gdańsk, Tuwima Str. 15 80-210, Gdańsk, Poland
- 2nd Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
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14
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Balasubramanian P, Delfavero J, Nyul-Toth A, Tarantini A, Gulej R, Tarantini S. Integrative Role of Hyperbaric Oxygen Therapy on Healthspan, Age-Related Vascular Cognitive Impairment, and Dementia. FRONTIERS IN AGING 2021; 2:678543. [PMID: 35821996 PMCID: PMC9261405 DOI: 10.3389/fragi.2021.678543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/09/2021] [Indexed: 12/17/2022]
Abstract
Growing life expectancy will contribute to the on-going shift towards a world population increasingly comprised of elderly individuals. This demographic shift is associated with a rising prevalence of age-related diseases, among all age-related pathologies it has become crucial to understand the age-associated cognitive changes that remain a major risk factor for the development of vascular cognitive impairment and dementia (VCID). Furthermore, age-related Alzheimer's disease and other neurogenerative diseases with vascular etiology are the most prominent contributing factors for the loss of cognitive function observed in aging. Hyperbaric Oxygen Therapy (HBOT) achieves physiologic effects by increasing oxygen tension (PO2), raising oxygen tissue levels, decreasing intracranial pressure and relieving cerebral edema. Many of the beneficial effects of HBOT exert their protective effects at the level of the microcirculation. Furthermore, the microcirculation's exquisite pervasive presence across every tissue in the body, renders it uniquely able to influence the local environment of most tissues and organs, including the brain. As such, treatments aimed at restoring aging-induced functional and structural alterations of the cerebral microcirculation may potentially contribute to the amelioration of a range of age-related pathologies including vascular cognitive impairment, Alzheimer's disease, and vascular dementias. Despite the presented evidence, the efficacy and safety of HBOT for the treatment of age-related vascular cognitive impairment and dementia remains understudied. The present review aims to examine the existing evidence indicative of a potential therapeutic role for HBOT-induced hyperoxia against age-related cerebromicrovascular pathologies contributing to cognitive impairment, dementia and decreased healthspan in the elderly.
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Affiliation(s)
- Priya Balasubramanian
- Vascular Cognitive Impairment and Neurodegeneration Program, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Jordan Delfavero
- Vascular Cognitive Impairment and Neurodegeneration Program, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Adam Nyul-Toth
- Vascular Cognitive Impairment and Neurodegeneration Program, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- International Training Program in Geroscience, Institute of Biophysics, Biological Research Centre, Eötvös Loránd Research Network (ELKH), Szeged, Hungary
| | - Amber Tarantini
- Vascular Cognitive Impairment and Neurodegeneration Program, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Rafal Gulej
- Vascular Cognitive Impairment and Neurodegeneration Program, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Stefano Tarantini
- Vascular Cognitive Impairment and Neurodegeneration Program, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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15
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Biggs AT, Dainer HM, Littlejohn LF. Effect sizes for symptomatic and cognitive improvements in traumatic brain injury following hyperbaric oxygen therapy. J Appl Physiol (1985) 2021; 130:1594-1603. [PMID: 33792399 PMCID: PMC8354823 DOI: 10.1152/japplphysiol.01084.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/24/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022] Open
Abstract
Hyperbaric oxygen therapy has been proposed as a method to treat traumatic brain injuries. The combination of pressure and increased oxygen concentration produces a higher content of dissolved oxygen in the bloodstream, which could generate a therapeutic benefit for brain injuries. This dissolved oxygen penetrates deeper into damaged brain tissue than otherwise possible and promotes healing. The result includes improved cognitive functioning and an alleviation of symptoms. However, randomized controlled trials have failed to produce consistent conclusions across multiple studies. There are numerous explanations that might account for the mixed evidence, although one possibility is that prior evidence focuses primarily on statistical significance. The current analyses explored existing evidence by calculating an effect size from each active treatment group and each control group among previous studies. An effect size measure offers several advantages when comparing across studies, as it can be used to directly contrast evidence from different scales, and it provides a proximal measure of clinical significance. When exploring the therapeutic benefit through effect sizes, there was a robust and consistent benefit to individuals who underwent hyperbaric oxygen therapy. Placebo effects from the control condition could account for approximately one-third of the observed benefits, but there appeared to be a clinically significant benefit to using hyperbaric oxygen therapy as a treatment intervention for traumatic brain injuries. This evidence highlights the need for design improvements when exploring interventions for traumatic brain injury and the importance of focusing on clinical significance in addition to statistical significance.
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Affiliation(s)
- Adam T Biggs
- Naval Special Warfare Command, Coronado, California
| | - Hugh M Dainer
- Naval Special Warfare Group FOUR, Virginia Beach, Virginia
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16
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Biggs AT, Littlejohn LF, Dainer HM. Alternative Uses of Hyperbaric Oxygen Therapy in Military Medicine: Current Positions and Future Directions. Mil Med 2021; 187:e40-e46. [PMID: 33564849 DOI: 10.1093/milmed/usab022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Hyperbaric oxygen therapy (HBOT) is a commonly used treatment for a variety of medical issues, including more than a dozen currently approved uses. However, there are alternative proposed uses that have significant implications among an active duty military or veteran population as treatments for PTSD, mild traumatic brain injury (mTBI), and traumatic brain injury (TBI). These applications have seen a recent groundswell of support from the operator and veteran communities, raising the visibility of using HBOT for alternative applications. The current review will cover the existing evidence regarding alternative uses of HBOT in military medicine and provide several possibilities to explain the potential conflicting evidence from empirical results. MATERIALS AND METHODS There were no inclusion or exclusion criteria for articles addressing currently approved HBOT uses as covered under the military health system. These references were provided for comparison and illustration as needed. For alternative HBOT uses, the review focuses explicitly upon three alternative uses in PTSD, mTBI, and TBI. The review addresses any piece of case study evidence, observational data, quasi-experimental design, or randomized-controlled trial that explored any or a combination of these issues within an active duty population, a veteran population, or a civilian population. RESULTS The existing medical evidence does not support a consensus viewpoint for these alternative uses of HBOT. Based on the literature review, there are four competing positions to explain the lack of consistency among the empirical results. These possibilities are described in no particular order. First, an explanation suggests that the results are because of placebo effects. The combination of participant expectations and subjective symptom reporting creates the potential that reported improvements are because of placebo rather than casual mechanisms. Second, another position suggests that experiments have utilized sham conditions which induced therapeutic benefits. If sham conditions have actually been weakened active treatment conditions, rather than placebo controls, it could explain the lack of observed significant differences in randomized clinical trials. Third, there has been a substantial amount of heterogeneity both in the symptoms treated and the treatments applied. This heterogeneity could explain the inconsistency of the data and the difficulty in reaching a consensus viewpoint. Fourth, the HBOT treatments may actively treat some tangential medical issue the patient is having. The treatment would thus promote an environment of healing without directly treating either PTSD, mTBI, or TBI, and the reduction in orthogonal medical issues facilitates a pathway to recovery by reducing tangential medical problems. CONCLUSIONS The mixed empirical evidence does not support recommending HBOT as a primary treatment for PTSD, mTBI, or TBI. If applied under the supervision of a licensed military medical professional, the consistently safe track record of HBOT should allow it to be considered as an alternative treatment for PTSD, mTBI, or TBI once primary treatment methods have failed to produce a benefit. However, the evidence does warrant further clinical investigation with particular emphasis on randomized clinical trials, better placebo controls, and a need to develop a consistent treatment protocol.
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Affiliation(s)
- Adam T Biggs
- Naval Special Warfare Command, Medical Department, Coronado, CA 92155, USA
| | - Lanny F Littlejohn
- Naval Special Warfare Command, Medical Department, Coronado, CA 92155, USA
| | - Hugh M Dainer
- Naval Special Warfare Group FOUR Medical Department, Virginia Beach, VA 23521, USA
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Abstract
Hyperbaric oxygen therapy, intermittent breathing of 100% oxygen at a pressure upper than sea level, has been shown to be some of the neuroprotective effects and used therapeutically in a wide range of neurological disorders. This review summarizes current knowledge about the neuroprotective effects of hyperbaric oxygen therapy with their molecular mechanisms in different models of neurological disorders.
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Affiliation(s)
- Fahimeh Ahmadi
- Molecular and Cell Biology Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ali Reza Khalatbary
- Molecular and Cell Biology Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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18
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Heslot C, Cogné M, Guillouët E, Perdrieau V, Lefevre-Dognin C, Glize B, Bonan I, Azouvi P. Management of unfavorable outcome after mild traumatic brain injury: Review of physical and cognitive rehabilitation and of psychological care in post-concussive syndrome. Neurochirurgie 2020; 67:283-289. [PMID: 33049290 DOI: 10.1016/j.neuchi.2020.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 08/26/2020] [Accepted: 09/13/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Mild Traumatic Brain Injury (mTBI) is a public health issue with approximately 42 million people worldwide affected yearly. Most patients have a favorable short-term recovery but 10-20% are likely to develop post-concussive syndrome (association of physical, cognitive, and psychological difficulties after injury). Post-concussive syndrome can be associated with Post-Traumatic Stress Disorder (PTSD). There is to date no recommendation on the interventions that could be done to reduce post-concussive syndrome. The present review aims at summarizing the effect of therapeutic education, physical and cognitive rehabilitation and of psychological care in mTBI patients with post-concussive syndrome. METHODS In the current international literature, we investigated the effects of therapeutic education, physical and cognitive rehabilitation and of psychological care in this population using the Medline database and we discussed the results of these studies. RESULTS The application of a therapeutic education intervention within 3 months after mTBI has been found appropriate and effective to prevent post-concussion syndrome in several studies but the timeline of this intervention differs among the existing studies. Concerning physical disabilities, several pharmacological, rehabilitative and non-pharmacological techniques have shown some efficacy in reducing headache and vertigo; rTMS seems also promising in this context. The management of fatigue is also crucial and requires a multidisciplinary approach. We did not find any intervention in mTBI patients with post-concussive syndrome suffering from dysosmia and/or dysgueusia. No pharmacological treatment is currently recommended to reduce the cognitive symptoms of post-concussive syndrome after mTBI. Rehabilitation and brain-stimulation techniques have already proven their efficacy to reduce the cognitive impairment in this population. Even if the use of Virtual Reality software seems well tolerated in this population, its efficacy and additional value needs to be demonstrated in larger studies. Concerning the psychological care after mTBI, Cognitive and Behavioral Therapy interventions are the most frequently reported in this population, followed by psychoeducational interventions. PTSD management seems crucial in overall recovery of patients with post-concussive syndrome. CONCLUSION Many studies have sought to demonstrate the effectiveness of various rehabilitation techniques, including different cognitive rehabilitation programs, technology-assisted rehabilitation, different types of brain stimulation and some pharmacological treatments. However, most of these studies are of a low level of scientific evidence and it would be necessary to carry out well-conducted prospective randomized trials in order to offer an appropriate and effective multidisciplinary management for patients with post-concussive syndrome after mTBI.
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Affiliation(s)
- C Heslot
- Rehabilitation Medicine Unit, Rennes University Hospital, 2, rue Henri-le-Guilloux, 35000 Rennes, France
| | - M Cogné
- Rehabilitation Medicine Unit, Raymond Poincaré Hospital, AP-HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France.
| | - E Guillouët
- Rehabilitation Medicine Unit, Raymond Poincaré Hospital, AP-HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France
| | - V Perdrieau
- Rehabilitation Medicine Unit, Raymond Poincaré Hospital, AP-HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France
| | - C Lefevre-Dognin
- Rehabilitation Medicine Unit, Raymond Poincaré Hospital, AP-HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France
| | - B Glize
- Rehabilitation Medicine Unit, Bordeaux University Hospital, place Amélie-Raba-Léon, 33000 Bordeaux, France; EA4136, Bordeaux University, 146, rue Léo-Saignat, 33000 Bordeaux, France
| | - I Bonan
- Rehabilitation Medicine Unit, Rennes University Hospital, 2, rue Henri-le-Guilloux, 35000 Rennes, France; Unit Empenn-U1228, INSERM, INRIA, University of Rennes 1, Rennes, France
| | - P Azouvi
- Rehabilitation Medicine Unit, Raymond Poincaré Hospital, AP-HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France; EA 4047 HANDIReSP, Versailles-Saint Quentin University, France
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MacLaughlin KJ, Barton GP, Braun RK, Eldridge MW. Effect of intermittent hyperoxia on stem cell mobilization and cytokine expression. Med Gas Res 2020; 9:139-144. [PMID: 31552878 PMCID: PMC6779002 DOI: 10.4103/2045-9912.266989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The best known form of oxygen therapy is hyperbaric oxygen (HBO) therapy, which increases both concentration and atmospheric pressure. HBO supports tissue regeneration and is indicated in an increasing number of pathologies. Less known but still showing some promising effects is normobaric oxygen (NBO) therapy, which provides some advantages over HBO including eliminating barotrauma risk, increased ease of administration and a significant cost reduction. However, still little is known about differences and similarities in treatment effects between HBO and NBO. Therefore we tested whether NBO induces a biological response comparable to HBO with a focus on stem progenitor cell mobilization and changes in serum cytokine concentration. We randomly assigned Sprague-Dawley rats into an NBO treatment group (n = 6), and a room air control group (n = 6). The NBO treatment group was exposed to 42% oxygen for 2 hours a day for 10 days. The room air group was concurrently kept at 20.9% oxygen. The frequency and number of stem progenitor cells in peripheral blood were analyzed by flow cytometry. Plasma cytokine expression was analyzed by cytokine array enzyme linked immunosorbent assay. All analyses were performed 24 hours after the final exposure to control for transient post treatment effects. The NBO treatment group showed an increase in circulating CD133+/CD45+ stem progenitor cell frequency and number compared to the room air control group. This rise was largely caused by CD34- stem progenitor cells (CD133+/CD34-/CD45+) without changes in the CD34+ population. The plasma cytokine levels tested were mostly unchanged with the exception of tumor necrosis factor-α which showed a decrease 24 hours after the last NBO exposure. These findings support our hypothesis that NBO induces a biological response similar to HBO, affecting serum stem progenitor cell populations and tumor necrosis factor-α concentration. The study was approved by Institutional Animal Care and Use Committee (IACUC) of the University of Wisconsin, Madison, WI, USA (approval No. M005439) on June 28, 2016.
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Affiliation(s)
- Kent J MacLaughlin
- Department of Pediatrics; John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin, Madison, WI, USA
| | - Gregory P Barton
- Department of Pediatrics; John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin, Madison, WI, USA
| | - Rudolf K Braun
- Department of Pediatrics; John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin, Madison, WI, USA
| | - Marlowe W Eldridge
- Department of Pediatrics; John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin, Madison, WI, USA
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Harch PG, Andrews SR, Rowe CJ, Lischka JR, Townsend MH, Yu Q, Mercante DE. Hyperbaric oxygen therapy for mild traumatic brain injury persistent postconcussion syndrome: a randomized controlled trial. Med Gas Res 2020; 10:8-20. [PMID: 32189664 PMCID: PMC7871939 DOI: 10.4103/2045-9912.279978] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022] Open
Abstract
Persistent postconcussion syndrome (PPCS) after mild traumatic brain injury (mTBI) is a significant public health and military problem for which there is limited treatment evidence. The aim of this study was to determine whether forty 150 kPa hyperbaric oxygen therapies (HBOTs) can improve symptoms and cognitive function in subjects with the PPCS of mTBI, using a randomized controlled crossover design with 2-month follow-up. Sixty-three civilian and military subjects with mTBI/PPCS were randomized to either 40 HBOTs at 150 kPa/60 minutes, once daily, 5 days per week in 8 weeks or an equivalent no-treatment control period. The Control Group was then crossed over to HBOT. Subjects underwent symptom, neuropsychological, and psychological testing, before and after treatment or control with retesting 2 months after the 40th HBOT. Fifty subjects completed the protocol with primary outcome testing. HBOT subjects experienced significant improvements in Neurobehavioral Symptom Inventory, Memory Index, Automated Neuropsychological Assessment Metrics, Hamilton Depression Scale, Hamilton Anxiety Scale, Post-Traumatic Stress Disorder Checklist, Pittsburgh Sleep Quality Index, and Quality Of Life after Brain Injury compared to the Control Group. After crossing over to HBOT the Control Group experienced near-identical significant improvements. Further improvements were experienced by both groups during the 2-month follow-up period. These data indicate that 40 HBOTs at 150 kPa/60 minutes demonstrated statistically significant improvements in postconcussion and Post-Traumatic Stress Disorder symptoms, memory, cognitive functions, depression, anxiety, sleep, and quality of life in civilian and military subjects with mTBI/PPCS compared to controls. Improvements persisted at least 2 months after the 40th HBOT. The study was registered on ClinicalTrials.gov (NCT02089594) on March 18, 2014 and with the U.S. Food and Drug Administration under Investigational New Drug #113823. The Institutional Review Boards of the United States Army Medical Research and Materiel Command Office of Research Protections Human Research Protection Office and the Louisiana State University School of Medicine (approval No. 7381) approved the study on May 13, 2014 and December 20, 2013, respectively.
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Affiliation(s)
- Paul G. Harch
- Department of Medicine, Section of Emergency and Hyperbaric Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Susan R. Andrews
- Department of Medicine and Psychiatry, School of Medicine, Louisiana State University Health Sciences Center, Metairie, LA, USA
| | - Cara J. Rowe
- CaTS Clinical Translational Unit, Tulane University School of Medicine, LA, New Orleans, LA, USA
| | | | - Mark H. Townsend
- Louisiana State University-Ochsner Psychiatry Residency Training Program, Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Qingzhao Yu
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Donald E. Mercante
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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Meehan A, Hebert D, Deru K, Weaver LK. Longitudinal study of hyperbaric oxygen intervention on balance and affective symptoms in military service members with persistent post-concussive symptoms. J Vestib Res 2019; 29:205-219. [PMID: 31282447 DOI: 10.3233/ves-180671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Dizziness and imbalance are common after mild traumatic brain injury (mTBI). Hyperbaric oxygen (HBO2) has been proposed for persistent post-concussive symptoms after mTBI, but its effect on vestibular function is unknown. OBJECTIVE To describe balance function in military service-members before and after intervention, and to explore the influence of post-traumatic stress disorder (PTSD), anxiety, and depression on vestibular outcomes. METHODS Seventy-one participants with mTBI and seventy-five healthy adults without brain injury were enrolled (NCT01611194 and NCT01925963). mTBI participants were randomized to 40 HBO2 sessions or 40 sham chamber sessions over 12 weeks. Normative controls received no intervention. Balance and neuropsychological function were measured at baseline, 13 weeks, and 6 months. RESULTS The mTBI cohort performed worse than healthy controls on balance and gait measures and reported more affective symptoms. Some within-group improvements were noted at 13 weeks and 6 months. Significant between-intervention differences on balance measures were minimal but effects on postural control generally favored HBO2. Those with affective symptoms, particularly PTSD, had the most improvement in postural control and otolith function following 13 weeks of HBO2. CONCLUSION HBO2 may influence balance function after mTBI, particularly in those with affective symptoms.
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Affiliation(s)
- Anna Meehan
- Lovelace Biomedical Research, Albuquerque, New Mexico, USA
| | | | - Kayla Deru
- Division of Hyperbaric Medicine Intermountain Medical Center, Murray, UT, and Intermountain LDS Hospital, Salt Lake City, UT, USA
| | - Lindell K Weaver
- Division of Hyperbaric Medicine Intermountain Medical Center, Murray, UT, and Intermountain LDS Hospital, Salt Lake City, UT, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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The Effect of Hyperbaric Oxygen Therapy on Functional Impairments Caused by Ischemic Stroke. Neurol Res Int 2018; 2018:3172679. [PMID: 30402285 PMCID: PMC6198568 DOI: 10.1155/2018/3172679] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022] Open
Abstract
Background While research suggests a benefit of hyperbaric oxygen therapy (HBOT) for neurologic injury, controlled clinical trials have not been able to clearly define the benefits. Objective To investigate the effects of HBOT on physical and cognitive impairments resulting from an ischemic stroke. Methods Using a within-subject design a baseline for current functional abilities was established over a 3-month period for all subjects (n=7). Each subject then received two 4-week periods of HBOT for a total of 40 90-minute treatments over a 12-week period. Subjects completed a battery of assessments and had blood drawn six times over the 9-month total duration of the study. Results We found improvements in cognition and executive function as well as physical abilities, specifically, improved gait. Participants reported improved sleep and quality of life following HBOT treatment. We also saw changes in serum levels of biomarkers for inflammation and neural recovery. In the functional domains where improvement was observed following HBOT treatment, the improvements were maintained up to 3 months following the last treatment. However, the physiological biomarkers showed a pattern of more transient changes following HBOT treatment. Conclusions Findings from this study support the idea of HBOT as a potential intervention following stroke.
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Dong Y, Hu XH, Wu T, Wang T. Effect of hyperbaric oxygenation therapy on post-concussion syndrome. Exp Ther Med 2018; 16:2193-2202. [PMID: 30186458 PMCID: PMC6122203 DOI: 10.3892/etm.2018.6463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 07/11/2017] [Indexed: 11/12/2022] Open
Abstract
The present review evaluated the effect of hyperbaric oxygenation (HBO) therapy on post-concussion syndrome (PCS). Searches for publications from the earliest date possible up until the first week of 2016 were conducted using the electronic databases Cochrane, EBSCOhost, Embase, Ovid MEDLINE, PubMed and Web of Science. Additional trials were identified through reference list scanning. Randomized controlled trials assessing the effectiveness of HBO therapy in PCS were selected and tested for eligibility for inclusion in the present review. Two independent reviewers conducted data extraction and the Cochrane Collaboration's recommended method was used to assess the risk of bias in each study included. Review Manager 5.3 software was used for data synthesis and analysis and the standardized mean difference (SMD) or mean difference (MD) was estimated with a fixed or random effects model using a 95% confidence interval (CI). A total of 127 articles were identified, 4 of which were eligible for final analysis. The meta-analysis identified no difference in the Rivermead Post-Concussion Symptoms Questionnaire (MD=1.23; 95% CI, -3.47-5.94; P>0.05; I2=35%) or Post-Traumatic Stress Disorder Checklist (PCL) scores (SMD=0.12; 95% CI, -0.31-0.54; P>0.05; I2=0%) scores between groups receiving different oxygen doses. The differences in PCL scores (SMD=-0.13, 95% CI, -0.80-0.53; P>0.05; I2=63%) and neurobehavioral symptoms (SMD=-1.00, 95% CI, -2.58-0.58; P>0.05; I2=92%) between the HBO and sham groups were not significant. The current study demonstrated that HBO therapy has no significant effect on PCS compared with the sham group. Therefore, it was determined that effective design and execution of a large clinical trial, which includes treatment, control and sham groups is required in the future.
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Affiliation(s)
- Yang Dong
- Department of Rehabilitation Medicine, Hangzhou Hospital of Zhejiang CAPF, Hangzhou, Zhejiang 310016, P.R. China
- Institute of Rehabilitation Medicine, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Xia Hua Hu
- Department of Rehabilitation Medicine, Hangzhou Hospital of Zhejiang CAPF, Hangzhou, Zhejiang 310016, P.R. China
| | - Tao Wu
- Department of Rehabilitation Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Tong Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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Lansdorp CA, van Hulst RA. Double-blind trials in hyperbaric medicine: A narrative review on past experiences and considerations in designing sham hyperbaric treatment. Clin Trials 2018; 15:462-476. [PMID: 29865904 PMCID: PMC6136075 DOI: 10.1177/1740774518776952] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Hyperbaric oxygen therapy, which consists of breathing 100% oxygen under a
higher atmospheric pressure than normal, is utilized worldwide in the
treatment of several diseases. With the growing demand for evidence-based
research, hyperbaric oxygen therapy has been criticized for delivering too
little high-quality research, mainly in the form of randomized controlled
trials. While not always indispensable, the addition of a sham-controlled
group to such a trial can contribute to the quality of the research.
However, the design of a sham (hyperbaric) treatment is associated with
several considerations regarding adequate blinding and the use of pressure
and oxygen. This narrative review discusses information on the sham profile
and the blinding and safety of double-blind trials in hyperbaric medicine,
irrespective of the indication for treatment. Methods MEDLINE, Embase and CENTRAL were searched for sham-controlled trials on
hyperbaric oxygen therapy. The control treatment was considered sham if
patients were blinded to their allocation and treatment took place in a
hyperbaric chamber, with no restrictions regarding pressurization, oxygen
levels or indication. Studies involving children or only one session of
hyperbaric oxygen were excluded. Information on (the choice of) treatment
profile, blinding measures, patient’s perception regarding allocation and
safety issues was extracted from eligible studies. Results A total of 42 eligible trials were included. The main strategies for sham
treatment were (1) use of a lower pressure than that of the hyperbaric
oxygen group, while breathing 21% oxygen; (2) use of the same pressure as
the hyperbaric oxygen group, while breathing an adjusted percentage of
oxygen; and (3) use of the same pressure as the hyperbaric oxygen group,
while breathing 21% oxygen. The advantages and disadvantages of each
strategy are discussed using the information provided by the trials. Conclusion Based on this review, using a lower pressure than the hyperbaric oxygen group
while breathing 21% oxygen best matches the inertness of the placebo.
Although studies show that use of a lower pressure does allow adequate
blinding, this is associated with more practical issues than with the other
strategies. The choice of which sham profile to use requires careful
consideration; moreover, to ensure proper performance, a clear and detailed
protocol is also required.
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Affiliation(s)
- C A Lansdorp
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Rob A van Hulst
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
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Is Hyperbaric Oxygen Therapy Effective for Traumatic Brain Injury? A Rapid Evidence Assessment of the Literature and Recommendations for the Field. J Head Trauma Rehabil 2018; 32:E27-E37. [PMID: 27603765 PMCID: PMC5426690 DOI: 10.1097/htr.0000000000000256] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Supplemental Digital Content is Available in the Text. Objective: This systematic review examines the efficacy of hyperbaric oxygen (HBO2) for traumatic brain injury (TBI) to make evidence-based recommendations for its application and future research. Methods: A comprehensive search was conducted to identify studies through 2014. Methodological quality was assessed and synthesis and interpretation of relevant data was performed. Results: Twelve randomized trials were included. All mild TBI studies demonstrated minimal bias and no statistically significant differences between HBO2 and sham arms. Statistically significant improvement occurred over time within both groups. Moderate-to-severe TBI studies were of mixed quality, with majority of results favoring HBO2 compared with “standard care.” The placebo analysis conducted was limited by lack of details. Conclusions: For mild TBI, results indicate HBO2 is no better than sham treatment. Improvements within both HBO2 and sham groups cannot be ignored. For acute treatment of moderate-to-severe TBI, although methodology appears flawed across some studies, because of the complexity of brain injury, HBO2 may be beneficial as a relatively safe adjunctive therapy if feasible. Further research should be considered to resolve the controversy surrounding this field, but only if methodological flaws are avoided and bias minimized.
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Li X, Li J, Yang X, Sun Z, Zhang J, Zhao W, Dong S, Li C, Ye Y, Chen J, Li Y, Xiang Y, Mao J, Li G, Guo H, Zhang W, Guo H, Zhang Y, Zhang M, Zhang W, Xu Z, Zhao B, Wei J, Zhao G, Ma R, Shen X, Ge C, Zheng C, Li S, Wang Y. Hyperbaric-Oxygen Therapy Improves Survival and Functional Outcome of Acute Severe Intracerebral Hemorrhage. Arch Med Res 2018; 48:638-652. [PMID: 29548729 DOI: 10.1016/j.arcmed.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/01/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Prognosis of spontaneous intracerebral hemorrhage (ICH) remains poor worldwide. AIMS OF THE STUDY To investigate the effect and optimal protocol for hyperbaric-oxygen therapy (HBOT), and reduce incidence of upper gastrointestinal bleeding (UGIB) in ICH. METHODS This prospective, randomized, controlled trial included 565 patients with acute severe ICH. Participants were randomly assigned to a sham-control group (Group A) and four intervention groups: Groups B and C with 2.0 atmospheres absolute (ATA) pressure and HBOT exposure for 60 or 90 sessions, respectively; and Groups D and E with 1.5 ATA for 60 or 90 sessions, respectively. All patients received emergency craniotomy with hematoma evacuation. Outcome measures were modified Barthel Index (MBI) and modified Rankin Scale (mRS) scores, mortality rates at follow-up six months. UGIB rates were assessed as potential side effect. RESULTS In four intervention groups, MBI and mRS scores were all significantly improved, and mortality rates were all significantly decreased compared with Group A (all p < 0.005). UGIB rates were 39.25, 60.00, 64.49, 36.79, and 34.26% in Groups A, B, C, D, and E, respectively. UGIB rates in Groups B and C were significantly increased compared with Groups A, D and E (all p < 0.005). None of UGIB were clinically significant. CONCLUSIONS HBOT significantly improves survival and functional outcomes of ICH. HBOT at 1.5 and 2.0 ATA had the same beneficial effect. A pressure of 1.5 ATA and 60 HBOT exposures represents an optimal protocol for HBOT. Further studies are needed to optimize the protocol per specific patient.
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Affiliation(s)
- Xiaowei Li
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China.
| | - Jingze Li
- Clinical Medicine Specialty of the First Clinical Medical College, Hebei North University, Changqing Road, Qiaoxi District, Zhangjiakou City, Hebei Province, People's Republic of China
| | - Xuehui Yang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Zhaosheng Sun
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Jinrong Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Wangmiao Zhao
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Shuzhi Dong
- Department of Hyperbaric Medicine, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Cong Li
- Department of Hyperbaric Medicine, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Yanqiao Ye
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Jianchao Chen
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Yongqian Li
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Yi Xiang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Jianhui Mao
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Guangjie Li
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Hong Guo
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Wenchao Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Hao Guo
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Yazhao Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Mingzhe Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Wanzeng Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Zhanyi Xu
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Baoshuai Zhao
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Jianhui Wei
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Gengshui Zhao
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Ronghua Ma
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Xiuzhi Shen
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Chunyan Ge
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Cunling Zheng
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Shang Li
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
| | - Yan Wang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui City People's Hospital), Affiliated Hospital of Hebei Medical University, Renmin East Road, Hengshui City, Hebei Province, People's Republic of China
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Harch PG, Andrews SR, Fogarty EF, Lucarini J, Van Meter KW. Case control study: hyperbaric oxygen treatment of mild traumatic brain injury persistent post-concussion syndrome and post-traumatic stress disorder. Med Gas Res 2017; 7:156-174. [PMID: 29152209 PMCID: PMC5674654 DOI: 10.4103/2045-9912.215745] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Mild traumatic brain injury (TBI) persistent post-concussion syndrome (PPCS) and post-traumatic stress disorder (PTSD) are epidemic in United States Iraq and Afghanistan War veterans. Treatment of the combined diagnoses is limited. The aim of this study is to assess safety, feasibility, and effectiveness of hyperbaric oxygen treatments (HBOT) for mild TBI PPCS and PTSD. Thirty military subjects aged 18-65 with PPCS with or without PTSD and from one or more blast-induced mild-moderate traumatic brain injuries that were a minimum of 1 year old and occurred after 9/11/2001 were studied. The measures included symptom lists, physical exam, neuropsychological and psychological testing on 29 subjects (1 dropout) and SPECT brain imaging pre and post HBOT. Comparison was made using SPECT imaging on 29 matched Controls. Side effects (30 subjects) experienced due to the HBOT: reversible middle ear barotrauma (n = 6), transient deterioration in symptoms (n = 7), reversible bronchospasm (n = 1), and increased anxiety (n = 2; not related to confinement); unrelated to HBOT: ureterolithiasis (n = 1), chest pain (n = 2). Significant improvement (29 subjects) was seen in neurological exam, symptoms, intelligence quotient, memory, measures of attention, dominant hand motor speed and dexterity, quality of life, general anxiety, PTSD, depression (including reduction in suicidal ideation), and reduced psychoactive medication usage. At 6-month follow-up subjects reported further symptomatic improvement. Compared to Controls the subjects' SPECT was significantly abnormal, significantly improved after 1 and 40 treatments, and became statistically indistinguishable from Controls in 75% of abnormal areas. HBOT was found to be safe and significantly effective for veterans with mild to moderate TBI PPCS with PTSD in all four outcome domains: clinical medicine, neuropsychology, psychology, and SPECT imaging. Veterans also experienced a significant reduction in suicidal ideation and reduction in psychoactive medication use.
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Affiliation(s)
- Paul G Harch
- Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Susan R Andrews
- Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Edward F Fogarty
- University of North Dakota School of Medicine, Bismarck, ND, USA
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Immediate and delayed hyperbaric oxygen therapy as a neuroprotective treatment for traumatic brain injury in mice. Mol Cell Neurosci 2017; 83:74-82. [DOI: 10.1016/j.mcn.2017.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 06/19/2017] [Accepted: 06/19/2017] [Indexed: 01/29/2023] Open
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Ostrowski RP, Stępień K, Pucko E, Matyja E. The efficacy of hyperbaric oxygen in hemorrhagic stroke: experimental and clinical implications. Arch Med Sci 2017; 13:1217-1223. [PMID: 28883864 PMCID: PMC5575217 DOI: 10.5114/aoms.2017.65081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/10/2016] [Indexed: 02/07/2023] Open
Abstract
Hemorrhagic stroke, accounting for 10-30% of stroke cases, carries high rates of morbidity and mortality. This review presents the current knowledge on the efficacy of hyperbaric oxygen (HBO)-based modalities in the preclinical research on hemorrhagic stroke. Both preconditioning and post-treatment with HBO are considered as prospective therapeutic options. High efficacy of HBO therapy (HBOT) for brain hemorrhage has been noted. We found that moderate hyperbaric pressures appear optimal for therapeutic effect, while the therapeutic window of opportunity is short. HBO preconditioning offers more modest neuroprotective benefit as compared to HBO post-treatment for experimental intracerebral hemorrhage. We advocate for mandatory calculations of percent changes in the experimentally investigated indexes of HBO effectiveness and stress the need to design new clinical trials on HBO for hemorrhagic stroke.
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Affiliation(s)
- Robert P Ostrowski
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Katarzyna Stępień
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Emanuela Pucko
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Ewa Matyja
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
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30
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Hawkins JR, Heumann KJ. Clinical Use of a Hyperbaric Chamber as a Modality to Aid in Recovery. Strength Cond J 2017. [DOI: 10.1519/ssc.0000000000000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fife CE, Eckert KA, Carter MJ. An Update on the Appropriate Role for Hyperbaric Oxygen: Indications and Evidence. Plast Reconstr Surg 2016; 138:107S-116S. [PMID: 27556750 PMCID: PMC4996355 DOI: 10.1097/prs.0000000000002714] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/03/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Among advanced therapeutic interventions for wounds, hyperbaric oxygen therapy (HBOT) has the unique ability to ameliorate tissue hypoxia, reduce pathologic inflammation, and mitigate ischemia reperfusion injury. Most of the conditions for which it is utilized have few successful alternative treatments, and the morbidity and mortality associated with treatment failure are significant. Data on the efficacy and effectiveness of HBOT were reviewed, comparative effectiveness research of HBOT was explained, and a new paradigm for the appropriate use of HBOT was described. METHODS Systematic reviews and randomized controlled trials that have evaluated HBOT were reviewed. RESULTS Although numerous small randomized controlled trials provide compelling support for HBOT, the physics of the hyperbaric environment create significant barriers to trial design. The electronic health record infrastructure created to satisfy mandatory quality and registry reporting requirements as part of healthcare reform can be harnessed to facilitate the acquisition of real world data for HBOT comparative effectiveness studies and clinical decision support. CONCLUSIONS Predictive models can identify patients unlikely to heal spontaneously and most likely to benefit from HBOT. Although electronic health records can automate the calculation of predictive models making them available at the point of care, using them in clinical decision making is complicated. It is not clear whether stakeholders will support the allocation of healthcare resources using mathematical models, but the current patient selection process mandates a 30-day delay for all patients who might benefit and allows treatment for at least some patients who cannot benefit.
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Affiliation(s)
- Caroline E Fife
- Houston and The Woodlands, Texas; and Cody, Wyo
- From the Baylor College of Medicine; The US Wound Registry; and Strategic Solutions, Inc
| | - Kristen A Eckert
- Houston and The Woodlands, Texas; and Cody, Wyo
- From the Baylor College of Medicine; The US Wound Registry; and Strategic Solutions, Inc
| | - Marissa J Carter
- Houston and The Woodlands, Texas; and Cody, Wyo
- From the Baylor College of Medicine; The US Wound Registry; and Strategic Solutions, Inc
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Hu Q, Manaenko A, Xu T, Guo Z, Tang J, Zhang JH. Hyperbaric oxygen therapy for traumatic brain injury: bench-to-bedside. Med Gas Res 2016; 6:102-110. [PMID: 27867476 PMCID: PMC5110132 DOI: 10.4103/2045-9912.184720] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Traumatic brain injury (TBI) is a serious public health problem in the United States. Survivors of TBI are often left with significant cognitive, behavioral, and communicative disabilities. So far there is no effective treatment/intervention in the daily clinical practice for TBI patients. The protective effects of hyperbaric oxygen therapy (HBOT) have been proved in stroke; however, its efficiency in TBI remains controversial. In this review, we will summarize the results of HBOT in experimental and clinical TBI, elaborate the mechanisms, and bring out our current understanding and opinions for future studies.
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Affiliation(s)
- Qin Hu
- Discipline of Neuroscience, Department of Anatomy, Histology and Embryology, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Anatol Manaenko
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ting Xu
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Zhenni Guo
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA; Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Hadanny A, Efrati S. Treatment of persistent post-concussion syndrome due to mild traumatic brain injury: current status and future directions. Expert Rev Neurother 2016; 16:875-87. [PMID: 27337294 DOI: 10.1080/14737175.2016.1205487] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Persistent post-concussion syndrome caused by mild traumatic brain injury has become a major cause of morbidity and poor quality of life. Unlike the acute care of concussion, there is no consensus for treatment of chronic symptoms. Moreover, most of the pharmacologic and non-pharmacologic treatments have failed to demonstrate significant efficacy on both the clinical symptoms as well as the pathophysiologic cascade responsible for the permanent brain injury. This article reviews the pathophysiology of PCS, the diagnostic tools and criteria, the current available treatments including pharmacotherapy and different cognitive rehabilitation programs, and promising new treatment directions. A most promising new direction is the use of hyperbaric oxygen therapy, which targets the basic pathological processes responsible for post-concussion symptoms; it is discussed here in depth.
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Affiliation(s)
- Amir Hadanny
- a The Sagol Center for Hyperbaric Medicine and Research , Assaf Harofeh Medical Center , Zerifin , Israel.,b Sackler School of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Shai Efrati
- a The Sagol Center for Hyperbaric Medicine and Research , Assaf Harofeh Medical Center , Zerifin , Israel.,b Sackler School of Medicine , Tel-Aviv University , Tel-Aviv , Israel.,c Research and Development Unit , Assaf Harofeh Medical Center , Zerifin , Israel.,d Sagol School of Neuroscience , Tel-Aviv University , Tel-Aviv , Israel
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Wang F, Wang Y, Sun T, Yu HL. Hyperbaric oxygen therapy for the treatment of traumatic brain injury: a meta-analysis. Neurol Sci 2016; 37:693-701. [PMID: 26746238 DOI: 10.1007/s10072-015-2460-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Abstract
Compelling evidence suggests the advantage of hyperbaric oxygen therapy (HBOT) in traumatic brain injury. The present meta-analysis evaluated the outcomes of HBOT in patients with traumatic brain injury (TBI). Prospective studies comparing hyperbaric oxygen therapy vs. control in patients with mild (GCS 13-15) to severe (GCS 3-8) TBI were hand-searched from medical databases using the terms "hyperbaric oxygen therapy, traumatic brain injury, and post-concussion syndrome". Glasgow coma scale (GCS) was the primary outcome, while Glasgow outcome score (GOS), overall mortality, and changes in post-traumatic stress disorder (PTSD) score, constituted the secondary outcomes. The results of eight studies (average age of patients, 23-41 years) reveal a higher post-treatment GCS score in the HBOT group (pooled difference in means = 3.13, 95 % CI 2.34-3.92, P < 0.001), in addition to greater improvement in GOS and lower mortality, as compared to the control group. However, no significant change in the PTSD score was observed. Patients undergoing hyperbaric therapy achieved significant improvement in the GCS and GOS with a lower overall mortality, suggesting its utility as a standard intensive care regimen in traumatic brain injury.
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Affiliation(s)
- Fei Wang
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China
| | - Yong Wang
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China
| | - Tao Sun
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China
| | - Hua-Lin Yu
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China.
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Eve DJ, Steele MR, Sanberg PR, Borlongan CV. Hyperbaric oxygen therapy as a potential treatment for post-traumatic stress disorder associated with traumatic brain injury. Neuropsychiatr Dis Treat 2016; 12:2689-2705. [PMID: 27799776 PMCID: PMC5077240 DOI: 10.2147/ndt.s110126] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Traumatic brain injury (TBI) describes the presence of physical damage to the brain as a consequence of an insult and frequently possesses psychological and neurological symptoms depending on the severity of the injury. The recent increased military presence of US troops in Iraq and Afghanistan has coincided with greater use of improvised exploding devices, resulting in many returning soldiers suffering from some degree of TBI. A biphasic response is observed which is first directly injury-related, and second due to hypoxia, increased oxidative stress, and inflammation. A proportion of the returning soldiers also suffer from post-traumatic stress disorder (PTSD), and in some cases, this may be a consequence of TBI. Effective treatments are still being identified, and a possible therapeutic candidate is hyperbaric oxygen therapy (HBOT). Some clinical trials have been performed which suggest benefits with regard to survival and disease severity of TBI and/or PTSD, while several other studies do not see any improvement compared to a possibly poorly controlled sham. HBOT has been shown to reduce apoptosis, upregulate growth factors, promote antioxidant levels, and inhibit inflammatory cytokines in animal models, and hence, it is likely that HBOT could be advantageous in treating at least the secondary phase of TBI and PTSD. There is some evidence of a putative prophylactic or preconditioning benefit of HBOT exposure in animal models of brain injury, and the optimal time frame for treatment is yet to be determined. HBOT has potential side effects such as acute cerebral toxicity and more reactive oxygen species with long-term use, and therefore, optimizing exposure duration to maximize the reward and decrease the detrimental effects of HBOT is necessary. This review provides a summary of the current understanding of HBOT as well as suggests future directions including prophylactic use and chronic treatment.
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Affiliation(s)
- David J Eve
- Department of Neurosurgery and Brain Repair, Center of Excellence for Aging and Brain Repair, Morsani College of Medicine
| | - Martin R Steele
- Veterans Reintegration Steering Committee, Veterans Research, University of South Florida, Tampa, FL, USA
| | - Paul R Sanberg
- Department of Neurosurgery and Brain Repair, Center of Excellence for Aging and Brain Repair, Morsani College of Medicine
| | - Cesar V Borlongan
- Department of Neurosurgery and Brain Repair, Center of Excellence for Aging and Brain Repair, Morsani College of Medicine
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Abstract
OBJECTIVES Objective measures to diagnose and to monitor improvement of symptoms following mild traumatic brain injury (mTBI) are lacking. Computerized eye tracking has been advocated as a rapid, user friendly, and field-ready technique to meet this need. DESIGN Eye-tracking data collected via a head-mounted, video-based binocular eye tracker was used to examine saccades, fixations, and smooth pursuit movement in military Service Members with postconcussive syndrome (PCS) and asymptomatic control subjects in an effort to determine if eye movement differences could be found and quantified. PARTICIPANTS Sixty Military Service Members with PCS and 26 asymptomatic controls. OUTCOME MEASURES The diagnosis of mTBI was confirmed by the study physiatrist's history, physical examination, and a review of any medical records. Various features of saccades, fixation and smooth pursuit eye movements were analyzed. RESULTS Subjects with symptomatic mTBI had statistically larger position errors, smaller saccadic amplitudes, smaller predicted peak velocities, smaller peak accelerations, and longer durations. Subjects with symptomatic mTBI were also less likely to follow a target movement (less primary saccades). In general, symptomatic mTBI tracked the stepwise moving targets less accurately, revealing possible brain dysfunction. CONCLUSIONS A reliable, standardized protocol that appears to differentiate mTBI from normals was developed for use in future research. This investigation represents a step toward objective identification of those with PCS. Future studies focused on increasing the specificity of eye movement differences in those with PCS are needed.
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37
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Hu Q, Manaenko A, Guo Z, Huang L, Tang J, Zhang JH. Hyperbaric oxygen therapy for post concussion symptoms: issues may affect the results. Med Gas Res 2015; 5:10. [PMID: 26306183 PMCID: PMC4547434 DOI: 10.1186/s13618-015-0033-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 08/05/2015] [Indexed: 01/24/2023] Open
Abstract
Post concussion syndrome (PCS) is a set of symptoms succeeding in 25 % of mild traumatic brain injury (mTBI) patients. Hyperbaric oxygen therapy (HBOT) has been demonstrated as an effective method for treating acute and severe TBI, but its efficacy in PCS remains controversial. In this editorial, we reviewed the clinical studies of HBOT in PCS, summarized the limitations of these studies, and discussed the limitations: inappropriate Sham group using room air at 1.2 or 1.3 ATA; delayed HBO administration; subjective assessment methods; time point for outcome assessment and small sample size. We hope that our concerns will be helpful for future clinical studies of HBO therapy in TBI or other neurological disorders.
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Affiliation(s)
- Qin Hu
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA USA
| | - Anatol Manaenko
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA USA
| | - Zhenni Guo
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA USA
| | - Lei Huang
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA USA
| | - Jiping Tang
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA USA
| | - John H Zhang
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA USA ; Department of Neurosurgery, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA USA
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38
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Cifu DX, Hoke KW, Wetzel PA, Wares JR, Gitchel G, Carne W. Effects of hyperbaric oxygen on eye tracking abnormalities in males after mild traumatic brain injury. ACTA ACUST UNITED AC 2015; 51:1047-56. [PMID: 25436771 DOI: 10.1682/jrrd.2014.01.0013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 04/30/2014] [Indexed: 11/05/2022]
Abstract
The effects of hyperbaric oxygen (HBO2) on eye movement abnormalities in 60 military servicemembers with at least one mild traumatic brain injury (TBI) from combat were examined in a single-center, randomized, double-blind, sham-controlled, prospective study at the Naval Medicine Operational Training Center. During the 10 wk of the study, each subject was delivered a series of 40, once a day, hyperbaric chamber compressions at a pressure of 2.0 atmospheres absolute (ATA). At each session, subjects breathed one of three preassigned oxygen fractions (10.5%, 75%, or 100%) for 1 h, resulting in an oxygen exposure equivalent to breathing either surface air, 100% oxygen at 1.5 ATA, or 100% oxygen at 2.0 ATA, respectively. Using a standardized, validated, computerized eye tracking protocol, fixation, saccades, and smooth pursuit eye movements were measured just prior to intervention and immediately postintervention. Between and within groups testing of pre- and postintervention means revealed no significant differences on eye movement abnormalities and no significant main effect for HBO2 at either 1.5 ATA or 2.0 ATA equivalent compared with the sham-control. This study demonstrated that neither 1.5 nor 2.0 ATA equivalent HBO2 had an effect on postconcussive eye movement abnormalities after mild TBI when compared with a sham-control.
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Affiliation(s)
- David X Cifu
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA
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Harch PG. Hyperbaric oxygen in chronic traumatic brain injury: oxygen, pressure, and gene therapy. Med Gas Res 2015; 5:9. [PMID: 26171141 PMCID: PMC4499900 DOI: 10.1186/s13618-015-0030-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 07/04/2015] [Indexed: 11/26/2022] Open
Abstract
Hyperbaric oxygen therapy is a treatment for wounds in any location and of any duration that has been misunderstood for 353 years. Since 2008 it has been applied to the persistent post-concussion syndrome of mild traumatic brain injury by civilian and later military researchers with apparent conflicting results. The civilian studies are positive and the military-funded studies are a mixture of misinterpreted positive data, indeterminate data, and negative data. This has confused the medical, academic, and lay communities. The source of the confusion is a fundamental misunderstanding of the definition, principles, and mechanisms of action of hyperbaric oxygen therapy. This article argues that the traditional definition of hyperbaric oxygen therapy is arbitrary. The article establishes a scientific definition of hyperbaric oxygen therapy as a wound-healing therapy of combined increased atmospheric pressure and pressure of oxygen over ambient atmospheric pressure and pressure of oxygen whose main mechanisms of action are gene-mediated. Hyperbaric oxygen therapy exerts its wound-healing effects by expression and suppression of thousands of genes. The dominant gene actions are upregulation of trophic and anti-inflammatory genes and down-regulation of pro-inflammatory and apoptotic genes. The combination of genes affected depends on the different combinations of total pressure and pressure of oxygen. Understanding that hyperbaric oxygen therapy is a pressure and oxygen dose-dependent gene therapy allows for reconciliation of the conflicting TBI study results as outcomes of different doses of pressure and oxygen.
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Affiliation(s)
- Paul G Harch
- Section of Emergency Medicine, Department of Medicine, Louisiana State University School of Medicine, 1542 Tulane Avenue, Rm. 452, Box T4M2, New Orleans, LA 70112 USA
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de Guise E, Alturki AY, Laguë-Beauvais M, LeBlanc J, Champoux MC, Couturier C, Anderson K, Lamoureux J, Marcoux J, Maleki M, Feyz M, Frasnelli J. Olfactory and executive dysfunctions following orbito-basal lesions in traumatic brain injury. Brain Inj 2015; 29:730-8. [DOI: 10.3109/02699052.2015.1004748] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- E. de Guise
- Neurology and Neurosurgery Department, McGill University Health Centre, Montreal, Quebec, Canada,
- Psychology Department, University of Montreal, Montreal, Quebec, Canada,
| | - A. Y. Alturki
- Neurology and Neurosurgery Department, McGill University Health Centre, Montreal, Quebec, Canada,
- Department of Neurosurgery, The National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia,
| | - M. Laguë-Beauvais
- Traumatic Brain Injury Program, McGill University Health Centre, Montreal, Quebec, Canada,
| | - J. LeBlanc
- Traumatic Brain Injury Program, McGill University Health Centre, Montreal, Quebec, Canada,
| | - M. C. Champoux
- Traumatic Brain Injury Program, McGill University Health Centre, Montreal, Quebec, Canada,
| | - C. Couturier
- Traumatic Brain Injury Program, McGill University Health Centre, Montreal, Quebec, Canada,
| | - K. Anderson
- Psychology Department, University of Montreal, Montreal, Quebec, Canada,
- Traumatic Brain Injury Program, McGill University Health Centre, Montreal, Quebec, Canada,
| | - J. Lamoureux
- Social and Preventive Medicine Department, University of Montreal, Montreal, Quebec, Canada,
| | - J. Marcoux
- Neurology and Neurosurgery Department, McGill University Health Centre, Montreal, Quebec, Canada,
| | - M. Maleki
- Neurology and Neurosurgery Department, McGill University Health Centre, Montreal, Quebec, Canada,
| | - M. Feyz
- Traumatic Brain Injury Program, McGill University Health Centre, Montreal, Quebec, Canada,
| | - J. Frasnelli
- Anatomy Department, Université du Quebec à Trois-Rivières, Trois-Rivières, Quebec, Canada, and
- Centre Avancé des Études sur le Sommeil, Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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Hyperbaric oxygen therapy can improve post concussion syndrome years after mild traumatic brain injury - randomized prospective trial. PLoS One 2013; 8:e79995. [PMID: 24260334 PMCID: PMC3829860 DOI: 10.1371/journal.pone.0079995] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/04/2013] [Indexed: 11/19/2022] Open
Abstract
Background Traumatic brain injury (TBI) is the leading cause of death and disability in the US. Approximately 70-90% of the TBI cases are classified as mild, and up to 25% of them will not recover and suffer chronic neurocognitive impairments. The main pathology in these cases involves diffuse brain injuries, which are hard to detect by anatomical imaging yet noticeable in metabolic imaging. The current study tested the effectiveness of Hyperbaric Oxygen Therapy (HBOT) in improving brain function and quality of life in mTBI patients suffering chronic neurocognitive impairments. Methods and Findings The trial population included 56 mTBI patients 1–5 years after injury with prolonged post-concussion syndrome (PCS). The HBOT effect was evaluated by means of prospective, randomized, crossover controlled trial: the patients were randomly assigned to treated or crossover groups. Patients in the treated group were evaluated at baseline and following 40 HBOT sessions; patients in the crossover group were evaluated three times: at baseline, following a 2-month control period of no treatment, and following subsequent 2-months of 40 HBOT sessions. The HBOT protocol included 40 treatment sessions (5 days/week), 60 minutes each, with 100% oxygen at 1.5 ATA. “Mindstreams” was used for cognitive evaluations, quality of life (QOL) was evaluated by the EQ-5D, and changes in brain activity were assessed by SPECT imaging. Significant improvements were demonstrated in cognitive function and QOL in both groups following HBOT but no significant improvement was observed following the control period. SPECT imaging revealed elevated brain activity in good agreement with the cognitive improvements. Conclusions HBOT can induce neuroplasticity leading to repair of chronically impaired brain functions and improved quality of life in mTBI patients with prolonged PCS at late chronic stage. Trial Registration ClinicalTrials.gov NCT00715052
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