Post-Concussion Syndrome and Hyperbaric Oxygen Therapy
Concussions are a form of traumatic brain injury. Concussions are most often thought of as minor injuries. However, the mechanism of these injuries results in the brain being jostled against the skull, causing damage to brain cells and resulting in biochemical changes that can have long lasting and potentially devastating effects.
According to the CDC, a TBI occurs every 15 seconds1 , leaving many with permanent disabilities and resulting in over $77 billion in healthcare and related costs2. Millions more were never seen by a healthcare professional because the injury thought to be insignificant. Sports related injuries are prominently ignored. Increased awareness of TBI and repetitive TBI in sports has been highlighted by players in the National Football League and has made TBI more of a national conversation. In fact, over 20% of middle and high school students reported a history of concussion3.
TBI can be divided into two general categories, the severe traumatic brain injury that results in hospitalizations, and the more common mild TBI. Although most resolve in 7-10 days, those that do not have persistent headaches, fatigue, anxiety, depression, insomnia and cognitive impairment. Very little progress has been made in the treatment and outcomes of both severe and mild TBI. Fascinating and cutting-edge therapies are starting to impact the treatment of this alteration in brain function. Hyperbaric oxygen is one of those emerging therapies.
The brain needs oxygen and energy to function optimally. An emerging concept is that these traumatic brain injuries are like wounds on other parts of our body, but not as readily visible. Exposure to hyperbaric oxygen increases the amount of oxygen that is carried by the blood. Because disruptions in blood flow are common in mTBI, HBOT allows for oxygen to be delivered and to facilitate healing. HBOT triggers healing by promoting the release of stem cells that can migrate to injured areas, promoting angiogenesis (the growth of new capillaries) and supporting energy production at the level of the mitochondria.
The most exciting research is being done in Israel on civilian patients with mTBI. This research is being led by Shai Efrati, MD. His team has published a series of articles that show excellent results inpatients with mTBI. They have had a marked reduction in symptoms, with many of them returning to normal levels of functioning. But these researchers have taken this a step further, by using advanced imaging techniques to show increases in cerebral blood flow/volume and the increase in white matter tracts, the physical improvements are now visible. Improvements that are seen clinically are being quantified.
Hyperbaric oxygen may be a very important clinical intervention in patient with mTBI when conventional modalities have not made a significant impact. Most treatment protocols are between 40 – 60 one-hour long treatments. Although controversy still exists surrounding its routine use, it is worth considering when patients have exhausted other therapeutic interventions.
Fig. 2. Average DSC maps pre and post HBOT and DSC normalized delta maps. Top row: CBF, CBV and MTT pre-HBOT. Middle row: CBF, CBV and MTT maps post-HBOT. Bottom row: normalized delta maps, showing increases in CBF and CBV and a decrease in MTT post-HBOT4.
FIGURE 5 | White matter tractography change in a single patient. (A) Fibers number increase in the right ILF tract. (B) Fibers number increase in the left IFOF tract. (C) Fibers increase in the right Uncinate tract5.
Sometimes seeing is believing. A decorated career combat veteran who had suffered at least 4 concussive injuries while on tours in Iraq and Afghanistan came to see us after having not responded to a couple of years of standard military TBI protocols. He complained of poor memory, irritability, chronic pain, headaches, severe insomnia and depression. He was being considered for discharge from the armed services due to his disabilities. When I first saw him he had a flat affect, and I worried about his daily commute from Columbus to Atlanta on his motorcycle. He assured me that he would not remember me the next time we met. About 5 week later I saw him again. Gone was the shell of a man, now he was bright, talkative and described his improved sleeping habits, decreased over all pain, and his ability to concentrate on his work. And he remembered me! This complete turnaround was astonishing to me. Although not a clinical trial, it gave me a different perspective on the work that is being done, and a small kernel of hope that we may have found a valuable tool in treating traumatic brain injury.
Chronic TBI patients are not the only ones who can benefit from HBOT. Those who have suffered a concussive injury, whether from sports or accidental, may benefit from early therapy (acute/subacute post-concussion). Many times, 3- 5 treatments are all that are required. Physicians who have treated college football players immediately after a concussive injury describe the headache being alleviated during the first treatment. What an amazing outcome!!
As more research begins to accumulate, and with increased utilization of advanced imaging techniques to quantify improvement, hyperbaric oxygen therapy should become more accepted as a treatment modality for TBI. Our trained panel of hyperbaric physicians are happy to see patients in consultation as discuss treatment options, including hyperbaric oxygen therapy as part of a comprehensive traumatic brain injury protocol.
1 Prins M, Greco T, Alexander D, Giza CC. The pathophysiology of traumatic brain injury at a glance. Disease Models & Mechanisms. 2013;6(6):1307-1315. doi:10.1242/dmm.011585.
2 Faul M., Xu L., Wald M. M., Coronado V. G. (2010). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
3 Veliz, Phil, et al. “Prevalence of concussion among US adolescents and correlated factors.” Jama 318.12 (2017): 1180-1182.
4 Tal, Sigal, et al. “Hyperbaric oxygen may induce angiogenesis in patients suffering from prolonged post-concussion syndrome due to traumatic brain injury.” Restorative neurology and neuroscience 33.6 (2015): 943-951.
5 Tal, Sigal, et al. “Hyperbaric oxygen therapy can induce angiogenesis and regeneration of nerve fibers in traumatic brain injury patients.” Frontiers in human neuroscience 11 (2017): 508.