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Atlanta Hyperbaric helps kids with traumatic brain injury, but for various reasons the problem tends to be understated.  As I discussed last week, the terminology we use can be confusing because parents and physicians alike often downplay a mild traumatic brain injury by calling it a concussion.  This week I mulled over the problem and found a report that points to some other subtleties of children after traumatic brain injury.

In a well controlled and designed study, the researchers looked at kids who came in the emergency room at Nationwide Children’s Hospital, Columbus, Ohio, who had head injuries and compared them with a control group of kids with arm or leg fractures.  The head-trauma group was carefully defined to include only mild traumatic brain injury with unconsciousness of less than 30 minutes.  All the children were reassessed at 3 weeks, 3 months, 6 months and a year.

Although it was not surprising, persistent symptoms such as amnesia, vomiting, headache, and dizziness occurred more often in the head trauma kids than in the fracture kids.  What did surprise me was how often the fracture kids had these kinds of brain-injury type symptoms.  The authors pointed out that all traumatic events will create some psychological problems but, obviously, if the whole issue were psychological, no differences between the head-injury group and the fracture group would have been found.  By the same token, if no psychological problems were involved, the fracture group would probably have had no long-term symptoms.

The authors were able to identify a group of kids at high risk for persistent brain-injury symptoms.  When they ranked the kids by severity, those in the high-severity group were three times more likely to have persistent symptoms.

Which people suffer long term problems following a bump on the head?  We frequently have to answer that question at Atlanta Hyperbaric and the current use of medical terms may add to the confusion.  At Atlanta Hyperbaric, we follow the Centers for Disease Control’s guidelines for the definition of Mild Traumatic Brain Injury (table.)

According to CDC, traumatic brain injury occurs 1.5 million times annually, with 50,000 deaths and 230,000 hospitalizations. Patients with mild traumatic brain injuries frequently suffer long-term memory problems as well as psychological and personality changes. At Atlanta Hyperbaric we aim to prevent and reverse these symptoms.

The real problem at Atlanta Hyperbaric comes up when someone says they had a concussion. Although concussion is also a medical term of art with a consensus definition that the CDC publishes, many patients and physicians use the terms “concussion” and “mild traumatic brain injury” interchangeably, and some use these terms in a confusing manner that suggests that a concussion is nothing to be concerned about.

This week I came across an interesting study that addressed this very issue. Among children admitted for a traumatic brain injury, those who were told they had a concussion were discharged significantly earlier and returned to school sooner than those who were not given the label. The authors concluded, “We suggest that the [concussion] label itself conveys a message and also directs outcomes….If we want to encourage full reporting with subsequent adequate management and convalescence, perhaps we should use the term ‘mild traumatic brain injury.’”

Some experts disagreed with this conclusion and I can understand why some would consider the whole issue a tempest in a teapot. I don’t. Hyperbaric oxygen helps these patients avoid long-term consequences. If telling parents that their child suffered a mild traumatic brain injury rather than a “mere” concussion helps to encourage further diagnosis and treatment, then let’s call a spade a spade.

The patients we see at Atlanta Hyperbaric who are referred for hyperbaric oxygen therapy for traumatic brain injury, are usually patients who are suffering the long, lingering effects of mild to moderate head trauma.  Our typical patient was involved in a motor-vehicle accident that caused a concussion; although he seemed to recover initially, he now has cognitive or emotional symptoms such as mood changes, confusion, and trouble with memory, concentration, attention, or thinking.   Our patient has struggled with his situation and had difficulties with his job, family and friends.  Someone finally suggested that perhaps hyperbaric oxygen might help.  Thousands of these people are walking around and few have been referred for hyperbaric oxygen therapy.

A new study came out last month that again showed the beneficial effect of hyperbaric oxygen for patients with traumatic brain injury.   Sixty-nine patients with severe traumatic brain injury were randomized to a one-hour hyperbaric-oxygen treatment at 1.5 ATA for 3 consecutive days, 3 hours of 100% oxygen or standard care.  Several sophisticated physiologic measurements were compared before, during and after treatment.  Without going into detail, the authors were able to conclude that hyperbaric oxygen was generally more “robust” than 100% oxygen for brain metabolism and they could find no evidence for any toxicity of the hyperbaric treatment.

Followers of this blog should not be surprised by these findings: More scientific evidence that hyperbaric oxygen has a beneficial effect to patients with brain injury.

Not long ago, medical students were taught the rule of thumb that if a person younger than about 60 remained conscious after head trauma, he likely did not suffer any permanent injury.  As psychological testing and radiologic imaging technology became more sophisticated over the years, however, this old straw had to be discarded.  Of course, my usual reaction is if mild head trauma causes measurable brain injury, why aren’t more of these patients offered hyperbaric oxygen therapy, the one treatment option that might actually be helpful?  More than a million Americans suffer from mild head trauma annually and perhaps 20% of these folks will never return to work.

My purpose today is not to whine about medical politics, but to bring attention to an article that appeared in the September 2009 issue of Radiology.  The study looked at 20 patients with mild head injuries, which was carefully defined, who all had diffusion tensor imaging.  That’s a mouthful, so let’s hold it here for a minute.

Diffusion tensor imaging is a type of fMRI (functional MRI)  that was first performed in 1991, but took almost another decade of hard work to develop to the point of relative widespread use.  Even today, fMRI is not available in all hospitals, but nevertheless, this article demonstrates just how useful DTI can be.  The patients seen in this study all had normal CT and MRI scans of the brain. In fact, the problem with mild head trauma is that there is no test that reliably predicts which patients are going to have long term problems. Enter the fMRI and more specifically DTI.

The 20 head-injured patients were matched with controls and subjected to a battery of psychological tests designed to assess executive function (errors of omission, number of maze trials, and maze time.)  The authors found 15 abnormal areas in the patients, compared to the controls, and were able to correlate injuries in the prefrontal cortex with abnormalities in measured executive function.

Although this is a small study, it demonstrates that as medicine advances, many patients with mild head injuries and normal brain scans do in fact have objective and measurable injuries.  We know that many of these patients will suffer for the rest of their lives.  Why not give them a chance with hyperbaric oxygen?

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A few weeks back, I wrote about the animal model of cerebral palsy.  Although animal models have pitfalls, by and large, medicine has often advanced through wise interpretation of these models.  Rats are often used because the scientist can do many experiments on a limited budget.

I always read the Journal of the Undersea and Hyperbaric Medical Society as soon as I receive it each quarter.  So, I must have read this animal study when it came out last year, but alas, I forgot about it.  I came across it again just recently and realized that I ought to make a few comments because this study has findings that are important to everyone interested in cerebral palsy.

The authors performed experiments on 180 rats!  I can hardly imagine recruiting 180 patients for any kind of human study, let alone one that involves hyperbaric oxygen.  In any case, the authors set up the cerebral palsy model in the rats and gave them one hyperbaric oxygen treatment daily for seven days. They carefully examined the hyperbaric-oxygen treated animals and compared them to the untreated ones and found that, within two weeks, neural stem cells had migrated into the cerebral cortex of the hyperbaric-treated animals and that, within four weeks, the treated animals actually had an increased number of neurons, i.e., the hyperbaric-treatment group actually grew brain tissue: the brain had partially repaired itself from the injury.

These results are really nothing short of astonishing.  We know that the brain has limited regenerative powers.  Here, however, after the severe damage caused by the experimental injury, prompt institution of hyperbaric oxygen not only stimulated neural stem cells to migrate into the damaged area, but these stem cells were able to differentiate into actual brain tissue, limiting the overall damage.  To the best of my knowledge, no other intervention of any kind has ever made this claim for the injured brain.

Dr. Paul Harsch of Louisiana posted this video showing the dramatic improvement of one of his brain-injured patients following treatment with hyperbaric oxygen.  The patient had been involved in an automobile accident that left him severely disabled and shows his progress over the course of 90 treatment sessions.  It is remarkable that this patient had been discharged after a prolonged rehabilitation program as essentially unimproved before he was even treated at Dr. Harsch’s clinic.  I have seen similar results in my practice.

Glenn L. Goodhart, M.D., J.D.