Treating Veterans with TBI & PTSD

Between 2000 and 2020, more than 430,000 US Service Members have experienced first lifetime Traumatic Brain Injury (TBI), not including service members who incur subsequent TBI’s(1). TBI’s are classified as mild, moderate, severe, or penetrating. They can occur from a sudden blow or jolt to the head from an impact, blast exposure, and even whiplash. Studies suggest that service members and veterans who have sustained a TBI may still have ongoing symptoms of post-concussive syndrome that go untreated. TBI of any severity can cause symptoms across multiple functional domains, including physical, cognitive, and psychological. 

In addition, among veterans with positive TBI screens, 80% indicate comorbid psychiatric diagnosis and up to half meet criteria for Post-Traumatic Stress Disorder (PTSD)(2). From the Vietnam war to Operation Enduring Freedom, Veterans suffering from PTSD has increased from 15% to 20%. PTSD is a complex psychiatric condition that develops in certain individuals after experiencing a major traumatic event(14). Behavioral symptoms of PTSD include re-experiencing the trauma, avoidance behavior, mood alternation, and hyperarousal(15). 

The negative impact that such symptoms and risks can make on one’s quality of life makes it clear that veterans with PTSD and TBI’s require safe, effective treatment options. Unfortunately, less than half of patients receiving traditional psychosocial treatments gain clinically meaningful improvements, and many continue to have residual symptoms(22-23). Thankfully, there is compelling evidence to suggest that Hyperbaric Oxygen Therapy (HBOT) may significantly reduce the negative symptoms experienced by TBI patients and PTSD patients, even years after the incident.

    What is Hyperbaric Oxygen Therapy?

    HBOT involves sitting in a hyperbaric chamber while breathing 100% medical grade oxygen through a mask or hood. The hyperbaric chamber gradually pressurizes to between 1.5 and 2.5 times the normal atmospheric pressure (referred to as 1.5 ATA and 2.5 ATA). This is equivalent to diving between 16 feet (1.5 ATA) and 50 feet (2.5 ATA) below water.

    The majority of HBOT treatments at Extivita are at 2.0 ATA, which is equivalent to 33 feet below surface level. Because oxygen is considered a drug by the FDA, patients must obtain a prescription from a licensed healthcare professional for these therapeutic treatments. The specific pressure is also included in the prescription. Our in-clinic provider can write HBOT prescriptions following your in-person consultation.

     

    Frequently Asked Questions About Hyperbaric Oxygen Therapy

    How do I get started with HBOT (new patients)?

    Before you come into the clinic, you will need to register as a patient in our patient portal. Here you will enter your medical history and primary reason/s for starting HBOT. After this, you will be able to schedule a consultation with Elena Schertz, FNP. You will be all set to begin treatment following your consultation!

    How is HBOT administered? 
    All Extivita patients have their very own hood or mask through which 100% medical grade oxygen is administered. These will be provided after your consultation. 
    What type of HBOT chambers do we use? 
    We have two hard-shell, multi-seat chambers at Extivita. Our biggest chamber can seat up to 12 patients, while our smaller chamber can seat up to 8 patients.  
    What can I do while in the HBOT chamber? 
    Whether it’s reading, watching a movie, or sleeping, there is plenty to do during your HBOT session. We have a TV in our largest chamber that we play movies on during most treatment sessions. In our smaller chamber, we have tablets that you can use to watch TV, browse the internet, or play games on. You are also more than welcome to bring your own book to read during treatment! 
    Will I be by myself during my HBOT session?  

    There will be a trained Extivita supervisor with you in all HBOT sessions. While you may be the only patient in the chamber on some days, most sessions will have other patients in the chamber as well. For additional information on how we are keeping our patients safe during COVID-19, click here.

    How long does an HBOT session last?  
    Most HBOT sessions will last roughly 1 hour and 30 minutes, which includes the time it takes to pressurize the chamber, 1 hour at the prescribed depth, and the time it takes to depressurize the chamber. Certain conditions may require shorter or longer durations at depth.  
    How many HBOT sessions are needed to improve PTSD and TBI Symptoms?

    This depends on the condition that you are receiving treatment for, as well as how your body responds to HBOT. The antioxidant and anti-inflammatory effects of HBOT can typically be felt within the first few sessions. Benefits for acute injuries and soft-tissue damage can typically be seen 5-10 sessions in, while chronic injuries typically require 10-20 sessions. Many conditions require 20-40 HBOT sessions for full healing effects such as stem cell increase.

    For TBI and PTSD patients, an initial HBOT regimen is typically 40 sessions. Symptom improvement is often experienced by patients between 10 and 20 sessions.

    Are there any side-effects to HBOT? 

    HBOT is generally considered one of the safest therapies in use today. Any serious side effects can be prevented by pre-HBOT screening that all patients receive during their consultation. One side effect that is some people experience is mild ear pain while the chamber pressurizes. However, this can be reduced through proper sinus clearing and it typically goes away as you receive more treatments.

    News & Research for Veterans with PTSD & TBI:

    Hyperbaric oxygen for mild traumatic brain injury: Design and baseline summary.

    Aug 3, 2017 | ,

    The Brain Injury and Mechanisms of Action of Hyperbaric Oxygen for Persistent Post-Concussive Symptoms after Mild Traumatic Brain Injury (mTBI) (BIMA) study, sponsored by the Department of Defense, is a randomized double-blind, sham-controlled clinical trial that has a longer duration of follow-up and more comprehensive assessment battery compared to recent HBO₂ studies. BIMA randomized 71 participants from September 2012 to May 2014. Primary results are expected in 2017. Randomized military personnel received hyperbaric oxygen (HBO₂) at 1.5 atmospheres absolute (ATA) or sham chamber sessions at 1.2 ATA, air, for 60 minutes daily for 40 sessions. Outcomes include neuropsychological, neuroimaging, neurological, vestibular, autonomic function, electroencephalography, and visual systems evaluated at baseline, immediately following intervention at 13 weeks and six months with self-report symptom and quality of life questionnaires at 12 months, 24 months and 36 months. Characteristics include: median age 33 years (range 21-53); 99% male; 82% Caucasian; 49% diagnosed post-traumatic stress disorder; 28% with most recent injury three months to one year prior to enrollment; 32% blast injuries; and 73% multiple injuries. This manuscript describes the study design, outcome assessment battery, and baseline characteristics. Independent of a therapeutic role of HBO₂, results of BIMA will aid understanding of mTBI.

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    Neuropsychological assessments in a hyperbaric trial of post-concussive symptoms.

    Aug 3, 2017 | ,

    Results of studies addressing the effect of mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) on symptoms and neuropsychological assessments are mixed regarding cognitive deficits in these populations. Neuropsychological assessments were compared between U.S. military service members with mTBI only (n=36) vs. those with mTBI÷ PTSD (n=35) from a randomized interventional study of mTBI participants with persistent post-concussive symptoms (PCS). The mTBI group endorsed worse symptoms than published norms on PCS, PTSD and pain scales (⟩50% abnormal on Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Civilian, McGill Pain Questionnaire-Short Form) and some quality of life domains. Worse symptom reporting was found in the mTBI÷ PTSD group compared to mTBI (e.g., mean NSI total score in mTBI 27.5 (SD=12.7), mTBI÷ PTSD 39.9 (SD=13.6), p⟨0.001). The mTBI÷PTSD group performed worse than mTBI on the Weschler Adult Intelligence Scale digit span (mean difference -1.5, 95% CI[-2.9,-0.1], p=0.04) and symbol search (mean difference -1.5, 95% CI[-2.7,-0.2], p=0.03) and Grooved Pegboard (dominant hand mean difference -7.0, 95% CI[-11.5,-2.4], p=0.003; non-dominant mean difference -9.8, 95% CI[-14.9,-4.7], p⟨0.001). Differences were detected in ANAM simple reaction time (p=0.04) and mathematical processing (p=0.03) but not verbal fluency or visuospatial memory assessments. Results indicate increased symptom severity and some cognitive deficits in mTBI÷ PTSD compared to mTBI alone.

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    Baseline EEG abnormalities in mild traumatic brain injury from the BIMA study.

    Aug 3, 2017 | ,

    The Brain Injury and Mechanisms of Action of HBO₂ for Persistent Post-Concussive Symptoms after Mild Traumatic Brain Injury (BIMA), sponsored by the Department of Defense, is a randomized, double-blind, sham-controlled trial of hyperbaric oxygen (HBO₂) in service members with persistent post-concussive symptoms following mild TBI, undergoing comprehensive assessments. The clinical EEG was assessed by neurologists for slow wave activity, ictal/interictal epileptiform abnormalities, and background periodic discharges. There is scant literature about EEG findings in this population, so we report baseline clinical EEG results and explore associations with other evaluations, including demographics, medication, neurological assessments, and clinical MRI outcomes. Seventy-one participants were enrolled: median age 32 years, 99% male, 49% comorbid PTSD, 28% with mTBI in the previous year, 32% blast injuries only, and 73% multiple injuries. All participants reported medication use (mean medications = 8, SD = 5). Slowing was present in 39%: generalized 37%, localized 8%, both 6%. No other abnormalities were identified. Slowing was not significantly associated with demographics, medication or neurological evaluation. Participants without EEG abnormalities paradoxically had significantly higher number of white matter hyperintensities as identified on MRI (p = 0.003). EEG slowing is present in more than one-third of participants in this study without evidence of associations with demographics, medications or neurological findings.

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