Hyperbaric oxygen therapy (1.5 ATA) in treating sports related TBI/CTE: two case reports

Effect sizes for symptomatic and cognitive improvements in traumatic brain injury following hyperbaric oxygen therapy

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.

Alternative Uses of Hyperbaric Oxygen Therapy in Military Medicine: Current Positions and Future Directions

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.

Effects of Exercise Training under Hyperbaric Oxygen on Oxidative Stress Markers and Endurance Performance in Young Soccer Players: A Pilot Study

The aim of the present study was to determine the effects of three weeks of hyperbaric oxygen (HBO₂) training on oxidative stress markers and endurance performance in young soccer players. Participants (18.6 ± 1.6 years) were randomized into hyperbaric-hyperoxic (HH) training (n = 6) and normobaric normoxic (NN) training (n = 6) groups. Immediately before and after the 5th, 10th, and 15th training sessions, plasma oxidative stress markers (lipid hydroperoxides and uric acid), plasma antioxidant capacity (6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid [TROLOX]), arterial blood gases, acid-base balance, bases excess (BE), and blood lactate analyses were performed. Before and after intervention, maximal oxygen uptake (VO₂max) and peak power output (PPO) were determined. Neither HH nor NN experienced significant changes on oxidative stress markers or antioxidant capacity during intervention. VO₂max and PPO were improved (moderate effect size) after HH training. The results suggest that HBO₂ endurance training does not increase oxidative stress markers and improves endurance performance in young soccer players. Our findings warrant future investigation to corroborate that HBO₂ endurance training could be a potential training approach for highly competitive young soccer players.

Hyperbaric oxygen therapy as a potential treatment for post-traumatic stress disorder associated with traumatic brain injury

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.

All the right moves: the need for the timely use of hyperbaric oxygen therapy for treating TBI/CTE/PTSD

Background

The modern age of hyperbaric medicine began in 1937; however, today few know about hyperbaric oxygen’s effects on the body and medical conditions outside of diving medicine and wound care centers - a serious ethical issue as there are 20 US military veterans committing suicide every day directly related to Traumatic Brain Injury/Post Traumatic Stress Disorder. The problem is not whether hyperbaric oxygen is effective for treating brain injuries, but why the interference in offering this therapy to those who need it.

Discussion

Up against black-boxed anti-depressants that are not efficacious, it should be a “no-brainer” to use a safe, off-label drug, but in the case of military veterans, every suicide might be seen as a tremendous cost saving to certain technocrats. The unspoken rationale is that if the military were to embrace hyperbaric oxygen as the efficacious therapy that it is then current active troops that have suffered injuries will come forward and seek treatment and benefits for their Traumatic Brain Injuries now that they know there is a viable therapy and in so doing troop strength will be decimated. So, to attempt to delay the acceptance of hyperbaric oxygen the Department of Defense has funded faux-studies claiming low pressure room air to be a placebo or sham, and then proclaiming there is no statistical difference between treatment arms and sham or placebo treatment arms. With few who understand hyperbaric medicine there is almost no one to call them on this subterfuge and prevarication. Many peer-reviewed articles have been published in the last decade that demonstrate hyperbaric oxygen is effective in repairing an injured brain even long after that injury took place. One of the most notable showed that blast-induced brain injured war veterans experienced a 15 point IQ increase (p < 0.001).

Summary

Hyperbaric oxygen is an efficacious, benign and humanitarian way to affect brain repair but it has not been adopted because it lacks patent protection and has no large corporate sponsors. It has also met interference because other agendas are present be they the protection of the status quo, myopic budgetary constraints, or perceived liability issues.

What's New in Traumatic Brain Injury: Update on Tracking, Monitoring and Treatment

Traumatic brain injury (TBI), defined as an alteration in brain functions caused by an external force, is responsible for high morbidity and mortality around the world. It is important to identify and treat TBI victims as early as possible. Tracking and monitoring TBI with neuroimaging technologies, including functional magnetic resonance imaging (fMRI), diffusion tensor imaging (DTI), positron emission tomography (PET), and high definition fiber tracking (HDFT) show increasing sensitivity and specificity. Classical electrophysiological monitoring, together with newly established brain-on-chip, cerebral microdialysis techniques, both benefit TBI. First generation molecular biomarkers, based on genomic and proteomic changes following TBI, have proven effective and economical. It is conceivable that TBI-specific biomarkers will be developed with the combination of systems biology and bioinformation strategies. Advances in treatment of TBI include stem cell-based and nanotechnology-based therapy, physical and pharmaceutical interventions and also new use in TBI for approved drugs which all present favorable promise in preventing and reversing TBI.

Hyperbaric oxygen treatment in autism spectrum disorders

Traditionally, hyperbaric oxygen treatment (HBOT) is indicated in several clinical disorders include decompression sickness, healing of problem wounds and arterial gas embolism. However, some investigators have used HBOT to treat individuals with autism spectrum disorders (ASD). A number of individuals with ASD possess certain physiological abnormalities that HBOT might ameliorate, including cerebral hypoperfusion, inflammation, mitochondrial dysfunction and oxidative stress. Studies of children with ASD have found positive changes in physiology and/or behavior from HBOT. For example, several studies have reported that HBOT improved cerebral perfusion, decreased markers of inflammation and did not worsen oxidative stress markers in children with ASD. Most studies of HBOT in children with ASD examined changes in behaviors and reported improvements in several behavioral domains although many of these studies were not controlled. Although the two trials employing a control group reported conflicting results, a recent systematic review noted several important distinctions between these trials. In the reviewed studies, HBOT had minimal adverse effects and was well tolerated. Studies which used a higher frequency of HBOT sessions (e.g., 10 sessions per week as opposed to 5 sessions per week) generally reported more significant improvements. Many of the studies had limitations which may have contributed to inconsistent findings across studies, including the use of many different standardized and non-standardized instruments, making it difficult to directly compare the results of studies or to know if there are specific areas of behavior in which HBOT is most effective. The variability in results between studies could also have been due to certain subgroups of children with ASD responding differently to HBOT. Most of the reviewed studies relied on changes in behavioral measurements, which may lag behind physiological changes. Additional studies enrolling children with ASD who have certain physiological abnormalities (such as inflammation, cerebral hypoperfusion, and mitochondrial dysfunction) and which measure changes in these physiological parameters would be helpful in further defining the effects of HBOT in ASD.