As a physician I would like to share my experience in evaluating and treating concussions (mild Traumatic Brain Injury- mTBI) in military and civilian patients over the last 3 years. In this article concussion and mTBI refer to identical injuries. This is a very pertinent discussion at this time due to the recent unfortunate shooting incident in Afghanistan by a US Military soldier diagnosed with TBI (traumatic brain injury). The Rand Corporation estimates there are over 350,000 US military men and women suffering from concussions symptoms (mTBI) and PTSD (Post Traumatic Stress Disorder) from blast incidents in Iraq and Afghanistan. Many of these wounded warriors are still trying to cope with their injured brain disabilities. Many are being redeployed after the diagnosis of TBI is made. They have not been able to return to a normal and productive lifestyle. In the civilian population concussions occur in more than 6 per 1,000 people each year. Common causes of civilian concussion are falls or blows to the head, motor vehicular accidents, bike accidents, sport injuries, or exposure to loud noises (explosion, etc). Most concussions (80-90%) resolve in a short period (7-10 days).
I was an active duty US Army physician from 1969 to 1971 and very familiar with military medicine. All of our recently treated concussed patients were months, some years, post concussion and still experiencing severe post concussion symptoms. One of my patients was a US Army Brig General concussed in Afghanistan by an IED explosion. His resulting concussion symptoms and cognitive impairment issues lasted for months before successful treatment with hyperbaric oxygen therapy.
In the past three years I have treated over 25 concussed (TBI) military patients for lingering concussion symptoms. I have been using hyperbaric oxygen therapy (HBOT) to treat these patients. None of these patients had life threatening head injuries. All had normal CT Scans/MRIs. Symptoms in these patients included cognitive impairment, loss of memory, headaches, depression, fatigue, anger and irritability, sleep disturbances, loss of multitasking and executive functions, and hypervigilance. All patients had successful results from HBOT therapy and either returned to full military duty, continued in school, or returned to full civilian employment.
The Department of Defense has developed criteria for the diagnosis of mTBI (Concussions) which must include one of the following
- Any period of loss of or decreased level of consciousness lasting less then 30 minutes
- Any loss of memory for events immediately before or after the injury lasting less than 24 hours after the event
- any alteration in mental state at the time of the injury such as confusion, disorientation, or slowed thinking lasting less than 24 hours
- transient neurological deficits (e.g. Weakness, loss of balance, change in vision, praxis, paresis or plegia, sensory loss, aphasia and
- Normal intracranial imaging.
All of our patients were previously treated by different agencies with medication only which gave them little or no relief in their disabling concussion symptoms. Our patients received a total of over 1400 HBOT treatments without any complications or adverse reactions. Patients were all treated in a rigid hyperbaric oxygen chamber at 1.5 ATA (17ft) on 100% oxygen for 60 minutes. The hyperbaric mTBI protocol calls for a minimum of 40 treatments with up to 80 treatments if necessary. Treatment plans and the need for additional HBOT treatments are based upon the clearing of concussion symptoms and improvement in Neuropsychological (neurocognitive) (NP) testing.
Neurocognitive testing is used to evaluate the concussed patient’s post injury neurocognitive condition and track improvements made with HBOT therapy. Neurocognitive testing is an assessment tool that can be used to identify changes in a patient’s cognitive function and mood state as a result of some debilitating event. Neurocognitive testing has become the most important modality in management and determination of a full recovery in concussed patients. The military NP test used was the ANAM (Automated Neuropsychological Assessment Metrics) test.
The ANAM was developed by the military to evaluate and follow the progress of TBI patients. A baseline NP test is performed before deployment with repeat testing following concussion injuries. During HBOT therapy the ANAM test is administered after each 20 HBOT treatments to document the progress and improvement in the injured brain. A different NP test is given to our civilian patients. All NP testing in done on an office computer and takes about 25 minutes. Report printouts are available immediately. These reports along with examination and discussions with the patient and family are used to determine if HBOT is indicated or needs to be continued.
There is controversy concerning the use of HBOT in the treatment of concussed patients. The majority of military mTBI patients are currently being treated primarily with prescription medications for their symptoms. Many of our military patients commented they were in a constant “brain fog” as a result of all the meds they were prescribed. They received sleeping pills if sleep was an issue, pain medication for headaches, antidepressants for depression, tranquilizers for anxiety and so forth. None of these medications treat the cause of TBI/PTSD which is the injured brain. Hyperbaric oxygen therapy through research and clinical use has demonstrated to be effective in repairing the injured brain. The current research is based upon both animal and human studies. There is a multitude of currently published medical literature demonstrating the benefit of HBOT in the treatment and repairing of injured brains.
Some of the criticisms in the use of HBOT treating concussions from different agencies are based upon the fact HBOT is not currently approved by the FDA in the specific treatment of mTBI. Many clinical studies are underway at this time studying the effectiveness of HBOT in the treatment of TBI/PTSD. The FDA will not approve procedures that are still in the clinical study mode. We as hyperbaric physicians have treated successfully hundreds of TBI/PTSD military personnel all with no adverse effects. HBOT is approved by the FDA to treat four types of brain injuries. These brain injuries include carbon monoxide poisoning, decompression sickness (Bends), arterial gas embolism to the brain, and acute blindness from central retinal artery occlusion. We as Physicians are allowed to use treatment modalities not FDA approved as long as, first, we do no harm to the patient and there is benefit in the treatment. We as a group of Physicians believe it is a mistake to currently deny these thousands of brain injured military personnel treatments which have shown to be completely effective in treating successfully and permanently mTBI and PTSD. Most of us treating hyperbaric physicians have not been paid at all by the military or the VA for our services to these injured men and women. I believe I speak for the group that we perform this service because we know it works, we respect the military and what it stands for, and that our injured men and women deserve the most effective currently available treatment for their injuries after putting their life on the line for our country.
Dr. Paul Harch MD gave testimony to the US House of Representatives last year pointing out that nearly all the medication being prescribed by Military Medicine and the Veterans Administration is being used “OFF-LABEL” as the standard of care for blast induced TBI and PTSD despite little or no research to support this prescribing. An estimated 120 combat Veterans per week or more than 10,000 overall have committed suicide according to the CDC numbers investigated by CBS News. The House Veteran Affairs Committee was told earlier that many of the suicides were related to the use of the FDA Black-Box drugs being use off-label These drugs carry specific warnings about increased suicide rates
Our first mTBI military patients were treated with HBOT in 2009. The two Airmen were in an armored semi-truck when they were involved in an IED explosion in Iraq. Neither man lost consciousness but they were dazed and somewhat confused initially. The both experienced the immediate onset of headaches. They were seen at an aid station later in the day, given acetaminophen, and returned to duty. Over a period of weeks these men began to experience debilitating concussive symptoms of severe headaches, memory loss, cognitive issues, anger/irritability issues and severe sleep disturbances. Upon returning to the US they were referred to our facility for HBOT by Col.(Dr) James Wright USAF Special Operations Command Surgeon and Board Certified Hyperbaric Physician.
Fortunately both men were given screening neuropsychological tests (ANAM) before they deployed to Iraq. We were able to compare their post injury tests with the baseline NP tests. Post injury testing revealed both men to be severely cognitively impaired from their concussions. Both men receive a series of HBOT treatments with NP testing after each 20 treatments. At the end of their HBOT treatments both men were completely free of all previous mTBI symptoms. Both airmen returned to their pre injury NP baseline scores after HBOT treatments. One man required 40 treatments and the other 80 HBOT treatments to return to their baseline NP scores. The Airmen are still on active duty. I recently spoke with both men and they are doing well without any concussion signs or symptoms. Col. Wright and I published a case report of these men in a major peer reviewed medical journal.
There is a lot of attention currently in the press and on the Internet regarding our TBI wounded men and women. There is an ongoing study NBIRR (national brain injury rescue rehabilitation) sanctioned by the Western Institutional Review Board (WIRB) using HBOT in concussed patients. There are 12 hyperbaric centers in the USA involved with this study. This study is an unfunded study and all treating facilities are providing the HBOT treatments to our injury veterans on their “nickel”. This study can be accessed by searching www.nbirr.org on the Internet and clicking on the “clinicaltrials.gov” box.
Dr. Paul Harch, Dr. James Wright, Dr. Bill Duncan, Dr. Rob Beckman and former Secretary of the Army Martin Hoffmann are currently playing key roles pro bono in an attempt to obtain funding for HBOT treatments for our wounded warriors. These men are meeting regularly with top Military officials and members of Congress in this attempt. The Navy League (www.navyleague.org) recently released a video on the use of HBOT treating TBI in military men and women. At the end of the video both the Chief of Naval Operations and the Commandant of the Marine Corps acknowledge at a congressional hearing their support for the use of HBOT in treating their TBI injured personnel.
Links to all publications, videos, references and military patient’s HBOT testimonials referred to in this article can be viewed at our web site, www.flhbot.com. I believe there may be a lot of response to this article. Some will be good, some may be critical. The VA and military do offer a variety of other treatment modalities to our wounded TBI troops. We believe the data and experience generated by the thousand of HBOT treatments used to successfully treat mTBI/PTSD warrants the acceptance by governmental agencies this method of treatment in our TBI/PTSD wounded men and women.
Respectfully, – Dr. Albert E. Zant MD (Eddie Zant MD)