BLOG #7: BLAST injury and Lessons for Patients and Parents
BRAIN DAMAGE FROM BLAST INJURY
Researchers confirmed in LANCET in June 2016 with solid science and objective physical evidence that blast injuries cause physical wounds to the brain. Formerly “invisible wounds” have been revealed through post-mortem autopsies to be both visible damage through Traumatic Brain Injury (TBI) as well as probable cause for secondary symptoms of PTSD and other debilitating, life-altering behavior. The implication of the finding is that those wounds should be and can be healed through application of “wound-healing” protocols in place for decades. And the simple fact is that there is a treatment that is proved with similar scientific evidence to be an already approved indication for wound healing: Hyperbaric Oxygen Therapy (HBOT).
Blast waves to the body, with or without unconsciousness, result in an immediate and significant metabolic crisis for the now wounded brain. Studies are underway to better link the acute pathobiology of blast injury with potential mechanisms of chronic cell death, dysfunction and neurodegeneration. Physiological damage — ripping and tearing and shearing and bleeding and bruising and swelling — lead to chaos in the head and link to clinical characteristics of concussion: balance problems, migraine symptoms, cognitive impairment and numerous other observable and measurable dysfunctions, and vulnerability to repeat injury.
Any combat veteran can attest to modern war’s effects on the brain. Ask any EOD, breacher, SpecOps, or survivor of an IED what they go through, and how inadequate “treatment” is after getting their heads rocked. Similar negligence is apparent in the “Concussion Protocols” in place around the world: “Wait a while, and we think you’ll get better.”
Medicine has well-known explanations of the nature of wounds and the phases in wound healing. The so-called “concussion cascade” that follows the wound to the head creates conditions that impede healing in the closed, heretofore unseen environment inside the skull. A blast or jolt to the head begins a series of negative consequences. These can include: inflammation; interrupted blood flow; oxygen starvation/hypoxia; tissue and nerve fiber ripping and tearing; cell stunning/ inactivation and/or cell death. This insidious biological set of degenerative processes may or may not lead to permanent damage. Unlike with a wound that can be seen, there is solid evidence that this brain inflammation can continue and linger for a long time, impeding healing and increasing the likelihood that more physical damage is occurring and is likely to occur. It has been “common knowledge” that most blast injuries and concussions heal themselves. That is far too simplistic. What may be true is that symptoms abate. Yet damage that can lead to mental and physical degeneration may lead to lingering symptoms and chronic degeneration.
The logical extension of the DOD/VA/Army findings in the LANCET article is that we must treat the wound to the brain using wound-healing protocols. The validity of using HBOT for healing the wound to the brain is validated in the most recent research. Unsurprisingly, delivering oxygen under pressure safely and economically leads to effective wound healing. And numerous other interventions for comorbid maladies have a much better chance of effectiveness when the concussion cascade is interrupted and reversed.
[a] Baughman Shively, S., Iren Horkayne-Szakaly, Robert V Jones, James P Kelly, Regina C Armstrong, Daniel P Perl. Characterisation of interface astroglial scarring in the human brain after blast exposure: a post-mortem case series. The Lancet, Neurology, June 2016. DOI: http://dx.doi.org/10.1016/S1474-4422(16)30057-6. In what is being called a breakthrough study, Dr. Daniel P. Perl and his team at the Uniformed Services University of the Health Sciences in Bethesda, Md., [the medical school run by the Department of Defense], have found evidence of tissue damage caused by blasts alone, not by concussions or other injuries. The New York Times calls it the medical explanation for shell shock: preliminary proof of what medicine has been saying without proof for nearly 100 years — blasts cause physical damage, and this physical damage leads to psychological problems, i.e., PTSD. The importance of this admission cannot be overstated: this is a DOD discovery with documented evidence that blast injury [IEDs, breeching–whether in training or combat, enemy and/or friendly fire from personal weapons and such systems as the Carl Gustav recoilless rifle] can lead directly to physical brain damage and the accompanying effects, many of which have been heretofore diagnosed as “only PTSD.”
[Commentary on above: Robert F. Worth. “What if PTSD is More Physical Than Psychological?,” The New York Times Magazine, June 10, 2016. http://nyti.ms/1TYYp6U A new study supports what a small group of military researchers has suspected for decades: that modern warfare destroys the brain.
[Additional commentary on above]: Alexander, Caroline. “Mystery of How Battlefield Blasts Injure the Brain May Be Solved. A landmark study sheds new light on the damage caused by “blast shock”—the signature injury of wars for more than a century.” National Geographic. JUNE 9, 2016 http://news.nationalgeographic.com/2016/06/blast-shock-tbi-ptsd-ied-shell-shock-world-war-one/
[b] Johns Hopkins Medicine. “Combat veterans’ brains reveal hidden damage from IED blasts.” ScienceDaily. ScienceDaily, 14 January 2015. <www.sciencedaily.com/releases/2015/01/150114140600.htm>.
[c] Xavier A. Figueroa, PhD and James K. Wright, MD (Col Ret), USAF Hyperbaric Oxygen: B-Level Evidence in Mild Traumatic Brain Injury Clinical Trials. Neurology® 2016;87:1–7 “There is sufficient evidence for the safety and preliminary efficacy data from clinical studies to support the use of HBOT in mild traumatic brain injury/ persistent post concussive syndrome (mTBI/PPCS). The reported positive outcomes and the durability of those outcomes has been demonstrated at 6 months post HBOT treatment. Given the current policy by Tricare and the VA to allow physicians to prescribe drugs or therapies in an off-label manner for mTBI/PPCS management and reimburse for the treatment, it is past time that HBOT be given the same opportunity. This is now an issue of policy modification and reimbursement, not an issue of scientific proof or preliminary clinical efficacy.”
[d] Wang F, et al. Hyperbaric oxygen therapy for the treatment of traumatic brain injury: a meta-analysis. Neurol Sci. 2016 Jan 8. PubMed PMID: 26746238. “Compelling evidence suggests the advantage of hyperbaric oxygen therapy (HBOT) in traumatic brain injury. …Patients undergoing hyperbaric therapy achieved significant improvement….with a lower overall mortality, suggesting its utility as a standard intensive care regimen in traumatic brain injury.”
Blast injury, and the accompanying role of air embolism in invisible wounds to the brain, is still not widely studied and thus seldom treated. Hyperbaric Oxygen Therapy is recognized worldwide as the definitive treatment for air embolism. Air/gas embolism is already an on-label, approved indication for HBOT.
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