Article cited by Alex Peterman Special to The Post

DELRAY BEACH — How does one heal that which cannot be seen?

It’s a riddle the Help Our Wounded (HOW) Foundation of South Florida is solving with science, targeting the most elusive of wounds that afflict the human body — brain injuries.

The “how” boils down to hyperbaric oxygen chambers — chambers filled with medical-grade oxygen at a higher-than-normal air pressure — that have fueled the healing missions of the Delray Beach-based nonprofit organization.

While medical literature has documented the benefits of hyperbaric oxygen therapy (HBOT or HBO) in a variety of treatment plans, the HOW Foundation has turned the page to a new chapter in its mission statement.

“We sat there and said, ‘All right, brain injuries. Who does that affect?’” said HOW Foundation Executive Director Sarah Crane, who has a master’s in cognitive neuroscience. “And we kind of looked at each other and were like, ‘Everybody.’ It’s one of those conditions that cuts across every demographic.”

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This was 2017. The foundation had just helped former Miami Dolphin Mark Duper. The polarizing movie “Concussion” about the NFL’s controversial handling of players’ concussions recently had come out.

The answer was clear: They would endeavor to help student-athletes.

The foundation’s new focus, named the Concussed Student-Athlete Program in 2020, developed and managed by Healthcare Education Director Hilary Loftus, quickly became a passion for all involved at the foundation, which sought money and resources to kick-start its new goal.

Today, the foundation seeks to use HBOT to reduce and even reverse the damage dealt to the brain by sports injuries, a process described by Drs. Daphne Denham and Joseph Maroon, consulting for the HOW Foundation.

Caroline Pagac, a University of Florida diver who hit the water headfirst and suffered a concussion, had three sessions in the hyperbaric chamber before she was feeling like herself again.
Maroon — neurosurgeon for the Pittsburgh Steelers for 39 years, as well as a board-certified clinical professor of neurological surgery at the Pittsburgh Medical Center — compared the brain’s inflammatory response to a concussion to the body’s response to a splinter.

“It gets red, hot, tender and swollen, right?” Maroon asks.

The brain reacts in much the same way, he says.

So when a person enters HBOT, several things occur.

“First and foremost, it hyper-oxygenates the tissues,” Denham says. “It gives that extra boost of oxygen that brain cells need to get better. The second thing it does is it reduces the swelling, so that blood flow can be restored to normal. And it turns off the inflammatory response.”

Even casual sports fans know that a bad helmet-to-helmet collision can cause a concussion.

But the lacrosse player who bangs his or her head on the field might not just be suffering from whiplash, and the diver who doesn’t complete a rotation and whose head hits the water first might not just be disoriented.


Medical-grade oxygen stimulates healing for concussed patients

Enter HBOT and its all-natural, comprehensive approach to brain recovery essentially augments the body’s own healing process.

Medical-grade oxygen stimulates healing in a fascinating way. Concussion patients often emerge from their sessions in the chamber — sometimes referred to as “dives” — completely different, commonly asymptomatic.

“The parents would come back and say, ‘you’ve given me my son back’ or ‘my daughter back,’” Maroon said.

Asher Bennett, 12, was the lacrosse player from Siegel High School in Tennessee whose head hit the field. Caroline Pagac was the University of Florida diver who hit the water headfirst.

“Everything was so slow-motion,” Pagac recalled after the injury. “It was like moving through Jell-O just doing daily tasks, so I knew something was wrong.”

The Bennett and Pagac families found the HOW Foundation, whose treatment by the Hyperbaric Services of the Palm Beaches in Delray Beach helped each athlete to make a significant recovery.

Caroline suffering from a concussion was a terrible sense of deja vu for the Pagac family, as the diver’s younger sister, Amanda, had suffered for a full year from a severe concussion in her youth.

Asher Bennett, 12, was playing lacrosse and suffered a concussion when his head hit the field, but his injury was not properly diagnosed until about a month later.
But for Caroline, it was a matter of three sessions in the hyperbaric chamber before she was feeling like herself again.

“As soon as I had gone into the oxygen chamber, prior to that,” she said, “I could maybe look at a computer three minutes at a time, but following that, I could look at the computer for longer periods of time. I could figure out more complex problems. It wasn’t as much of a strain on my brain.”

After one session, her physical therapist proclaimed she was 50% better. After one more, she was symptom-free — and she was quickly cleared to resume competitive diving the following semester.

Things happened differently for the Bennett family, who didn’t have the same prior experience with head injuries. In fact, no one who witnessed the injury on the lacrosse field considered the possibility of a concussion.

His coach guessed Bennett was dehydrated in the typical South Florida heat. Because the young lacrosse player was quiet about his symptoms, he was even briefly put back into the game.

“I started seeing colors and stuff, and got very dizzy,” Bennett said.

The symptoms worsened over the course of a month. He made two trips to the hospital, and suffered a chronic headache.

He saw multiple doctors, but none offered a solution. The tests, including scans, came back normal, so they sent him home.

These symptoms were the manifestation of what the medical literature calls post-concussion syndrome. Denham notes that any concussion left untreated after 28 days is categorized as chronic.

After 12 sessions in the hyperbaric chamber, Bennett is now doing much better. But his is a cautionary tale.

While safe, HBOT technicians will ask patients to refrain from wearing makeup, nail polish and deodorant, and to wear all-cotton clothing.

But once inside, it’s a comfortable setting. Patients watch television to distract them from the increased pressure in the ears, and they’re welcome to bring a plastic water bottle with them.


Timing is everything with head injuries

Just like procrastination with schoolwork or delaying an offseason regimen can affect a student-athlete’s preparation, waiting to seek help for a head injury can drastically alter the recovery timeline.

And even though we cannot see it with the naked eye, a traumatic brain injury reacts in much the same way as any physical ailment.

Healthcare Education Director Hilary Loftus developed and manages the HOW Foundation’s Concussed Student-Athlete Program.
“If you have a broken ankle, you don’t want to continue running on this ankle because it can only get worse,” says Dr. Shai Efrati, founder of the Sagol Center for Hyperbaric Medicine and Research at Shamir Medical Center in Israel.

Efrati also serves as the chair of the Aviv Clinic’s advisory board in Ocala, a clinic that treats people with hyperbaric oxygen therapy using a specific protocol — a protocol that even Maroon has taken part in before comparing before-and-after neurological tests to further assist his research into the benefits of HBOT.

Studies show that many athletes — among others — who suffer a concussion will heal on their own, without significant medical intervention.

But some aren’t so lucky.

“There’s a small cohort that doesn’t [recover on their own], and they’re left with memory impairment, mood disturbances, headaches, migraine, a whole host of symptoms that can be incapacitating,” Maroon says.

In these cases, the symptoms may last for weeks or months — even years. And for those brain injuries that do not heal on their own, the longer one waits, the longer the treatment required for one to get back to normal.

“It’s insane,” Denham says. “The philosophy of these quote-unquote concussion doctors is that you just have to accept your ‘new normal.’ Normal is a cycle on the washing machine. We’re not accepting anything. ‘Normal’ doesn’t need an adjective. ‘New normal’ is not normal.”

Whereas Efrati’s team with the Aviv Clinic frequently handles brain injuries that might be considered chronic using their 12-week protocol, Denham says the vast majority of her patients have “acute concussions,” categorized in medical literature as those brain injuries less than 10 days old from the injury.

When student-athletes or others seek HBOT within the first 10 days of their injury, the number of sessions needed often drops dramatically. On average, there are 3 1/2 to 4 treatments.

The treatments are described as very nonintrusive. Oxygen-based therapies are largely very safe, usually with no side effects when administered professionally, such as by Hyperbaric Center of the Palm Beach’s senior technician Anne Marie Heid, who is also a nationally registered emergency medical technician and diver medical technician.

Heid describes the process of being in the hyperbaric chamber: “The closest thing if you’ve never scuba-dived is flying in a plane. When you ascend and descend, you feel the pressure in your ears and you need to clear. That’s the most common thing that you feel.”

Hyperbaric Services of the Palm Beaches is the first freestanding facility to receive accreditation from JCAHO, the Joint Commission on Accreditation of Healthcare Organizations.

Committing to several sessions is a small investment of time. But the financial toll can be steep; each session typically costs around $250.

However, through funding from organizations such as Palm Health Foundation, HOW and its partners have committed to helping student-athletes by providing treatment without charge.

“Youth mental health and wellness is important to us at Palm Health Foundation, and many of the grant programs we fund have a focus on supporting and uplifting our young people,” President and CEO Patrick McNamara said in a statement to The Palm Beach Post. “HOW helps student-athletes suffering from traumatic brain injuries return to a normal life — a life in which they can continue to thrive and contribute to our wonderful community.”

Palm Health Foundation’s statement also identifies an oft-missed aspect of brain injuries — the mental health ramifications.

The HOW Foundation’s original mission was to help veterans with post-traumatic stress disorder (PTSD), a goal that Crane says was inspired by her grandmother.

“I’m just the implementer, but I can’t take credit for the vision,” Crane said, explaining that her grandmother had witnessed her younger brother suffer tremendously with survivor’s guilt from the war in the South Pacific.

Having herself experienced the benefits of hyperbaric treatment, Crane’s grandmother sought to make HBOT available to all veterans, so that no one would have to go through what her brother had.

It was this endeavor that gave birth to Hyperbaric Services of the Palm Beaches, the facility that now treats both veterans and student-athletes alike, among others.

Maroon echoed the dangerous effects of PTSD, calling it the primary reason why 18-22 veterans commit suicide every day.

Dr. Raymond Cralle, registered phlebotomy technician, calls it “the silent wounds of war.” As a marine veteran himself, Dr. Cralle was inducted into the Florida Hall of Fame Society for his pro bono treatments of PTSD using HBOT.

It was from the combined efforts of Maroon and Cralle’s hyperbaric treatment knowledge that Ray Shazier, former linebacker for the Pittsburgh Steelers, was able to walk again after suffering a spinal cord injury during a hit when playing against the Cincinnati Bengals in December 2017.

Just as concussions do not discriminate between age, gender, or ethnicity, neither does mental illness – a broad-spectrum term that, like concussions, affects everyone handling it in different ways.


Suicide remains risk for those who suffer a concussion

An analysis led by Michael Fralick with Harvard’s School of Public Health, which looked at 17 studies encompassing 700,000 people who had been diagnosed with concussions, found that individuals who suffer even one concussion or instance of traumatic brain injury had double the risk of suicide.

Former athletes who have committed suicide in the wake of chronic traumatic encephalopathy (CTE) symptoms should serve as a stark warning of the dangers of head injuries.

“Some concussions seem to cause the brain to start eating itself,” Dr. Raymond Cralle says. “So you quit playing football, but the damage is continuing to dissolve the brain tissue over time. And that’s what’s so horrible.”

That represents a more extreme case of traumatic brain injury, such as that which Cralle says played a significant role in former New England Patriots tight end Aaron Hernandez’s brain degeneration.

But even much smaller concussive blows can affect mental health.

And while it’s the star athletes who often make the headlines, it’s a real fear for the young student-athletes in our own backyard.

Linden Perry was the first pediatric patient to undergo the Aviv Clinic’s protocol. Although the HBOT treatment worked well, her mother, Carissa Perry, acknowledges her daughter was a shadow of herself following the basketball injury that left her concussed.

“‘Unlimited potential’ is pretty much how she has been described when it comes to her academics and athletics,” Carissa said.

“And then post-injury, she existed in a fog, always,” she continued. “I can’t explain how different she was. There was no quick wit. There was no processing speed on anything. It was like she didn’t exist. She struggled so much to do basic things. Everything she felt was a strength about herself suddenly became a weakness. And it was really hard to watch.”

Anxiety and depression are common side effects of concussions, and suicidal thinking has wreaked havoc on many athletes’ lives. But the HOW Foundation wants to make certain that student-athletes aren’t facing those fears alone.

“One of the things that the HOW Foundation does is that we make the invisible visible,” Crane says. “It’s taking these two things that are unknown and putting them in the spotlight, and there’s a lot of education that comes along with that. We like to provide as much knowledge as possible. If they say ‘knowledge is power ‘ we’re like, ‘we’re going to give you all the power. Take it and run with it. Use it.’ ”

Dr. Daniel Kantor, chair of the Concussion Subcommittee for the Sports Medicine Advisory Committee for the Florida High School Athletic Association, compares our current knowledge of concussion treatment to where we were with many brain diseases 50 years ago.

“We tell our student-athlete patients, ‘well, we can diagnose you with concussion and we can make you return to play in a slow, stepwise approach, but there’s nothing we can do for you,’ ” Kantor says. “And I think that’s really where the HOW Foundation falls into place. That’s where hyperbaric oxygen therapy makes sense. It’s not a medication. It’s a treatment.”

Until the research reaches the necessary checkpoint, it’s up to foundations like HOW to serve their communities.

When Crane speaks on HOW’s mission with the Concussed Student-Athlete Program, another paradox enters the equation.

“The ultimate goal of HOW Foundation is sort of ironic,” Crane says. “We eventually hope to be able to put ourselves out of business.”

If you know a concussed student-athlete who needs help, go to and fill out the “initial questionnaire” under New HBOT Candidate, or call Hilary Loftus at 561-450-6213.