CLINICAL IMPROVEMENT POST CONCUSSION SYNDROME WITH

OXYGEN HYPERBARIC THERAPY

Mardoni Setiawan, MD*, Maxmillian Ch. Oley, MD, PhD**, Eko Prasetyo, MD, PhD**,
Mendy Hatibie, MD, PhD***
* General Surgery Resident RSUP Prof. Dr.R.D. Kandou/ Faculty of Medicine Unsrat, Manado
** Department of Neurosurgery RSUP Prof. Dr.R.D. Kandou/ Faculty of Medicine Unsrat, Manado
*** Department of Plastic Surgery RSUP Prof. Dr.R.D. Kandou/ Faculty of Medicine Unsrat, Manado

Objectives: To prove that hyperbaric oxygen therapy (TOHB) accelerates the process of healing the
symptoms of mild head injury patients (post-Komosio syndrome).

Methodes: The study gained as many as 20 Mild Head Injury patients and were included in
the study. The study uses a controlled trial plan comparing the outcome condition of 2
treatment groups, i.e. Mild Head Injury patient with TOHB vs control.

Results: The results of this study proved that there is a decline in the Rivermead Post-
Concussion Symptoms Questionnaire (RPQ) score, both the RPQ-3 and the RPQ-13 meaning
(p < 0.001) in Mild Head Injury patients treated with TOHB. The effectiveness of the TOHB
in this condition is also seen in the change of scores, both involving the initial symptoms
(RPQ-3) and further (RPQ-13) in the Mild Head Injury patient. Values of RPQ score
reduction for both groups of items is quite large (-3.80 in RPQ-3 and-16.20 in RPQ-13) on
TOHB administration compared without TOHB.

Conclusion: This research has proven the influence of TOHB accelerate the process of

healing the symptoms of Mild Head Injury patients (post-Komosio syndrome).

Keywords: Hyperbaric Oxygen Therapy, post-Komosio syndrome, Rivermead Post-

Concussion Symptoms Questionnaire.

INTRODUCTION

Head injuries are a leading cause of death and disability among young adults and are a

major health and socioeconomic problem around the world.1,2 Symptoms of this injury vary,

ranging from mild, moderate to severe, depending on the area of brain that has been damaged.

Head injury Patients often experience significant cognitive impairments, behaviors, and

communication.3 At a present in Indonesia , a head injury is the cause of nearly half of the

overall death due to trauma, given that the head is the most frequent and vulnerable involved

in an accident.4

TOHB is the use of 100% oxygen at a higher pressure than atmospheric pressure.5,6,7

Patients will inhale 100% oxygen gradually and in conjunction with increased therapeutic

room pressure to more than 1 absolute atmosphere (ATA).5,8

TOHB is the current concern in neurology and is proven to inhibit apoptosis, suppress

inflammation, protect the integrity of the blood brain barrier, as well as supporting

angiogenesis and neurogenesis.9,10

In chronic brain injury, TOHB improves cerebral blood flow, corrects

neuropsychological disorders, and enhances neurophysiological and electrophysiological

improvements This therapy is also reported to provide a positive effect by enhancing the

quality of life in patients with post-Komosio or Mild Head Injury syndrome in advanced

chronic stage.11 This shows the success of intensive TOHB use as therapeutic modalities in

various patients with head injuries.11-3

 Common symptoms often occured after Mild Head Injury is known as a post-Komosio

syndrome. Most patients with Komosio post syndrome healed within 3 to 6 months.14-7 In

most clinical trials, the outcomes were evaluated by neuropsychological examinations, one of

which was RPQ.18

RESEARCH METHODOLOGY

20 patients were included in this study. The study uses a controlled trial plan comparing

the outcome conditions of two treatment groups, i.e. Mild Head Injury patients with TOHB vs

control. The control group will receive standard Mild Head Injury therapy according to the

Advanced Trauma Life Support (ATLS) protocol. After being treated according to the ATLS

protocol, the TOHB group will get a TOHB session, which is 2 − 3 ATA pressure oxygen

with 100% oxygen in high-pressure air space, for 60 minutes.

The results showed that male patients were more than women, aged between 13 and 66

years. They were average of nearly 40 years old but with quite large variations (SD 15 years

old). There are no significant differences in the age of the patients in the TOHB and control

groups. The comparison between males and females was about 6.5:3.5 and the ratio was

relatively unchanged while being stratificated according to the TOHB vs. control group.

Overall, the characteristics of patients in both groups are relatively indifferent become

important to noted. The absence of such difference suggests that the selection bias relating to

age, sex or the location of intracranial hemorrhage may be removed.

Before the therapeutic action, both research groups examined the RPQ score and the

head CT Scan . In the group with the treatment, TOHB is administered in the first, third and

fifth weeks. In the control group is given only standard Mild Head Injury therapy. In the fifth

week of post-therapy, patients with TOHB and control rated RPQ scores, and head CT Scan.
RESEARCH RESULT

RPQ Score

Tabel 1. Shows the value of the outcome studied, which is the RPQ score at each test

time. All outcomes are examined before a special action against a Mild Head Injury patient

and in the fifth week after therapy. In addition to the test results, table 1. Also presents the

difference in values between the fifth week and the measurements before the therapy begins

(delta).

The results showed that from RPQ-3 and RPQ-13 there was a significant decline in score.

RPQ scores, both the initial items (RPQ-3) that relate to the symptoms beginning of the head or

thirteenth injury of the next item (RPQ-13) which contains the further symptoms of head injury,

are no different in the second research group before treatment is performed. But at the end of the

fifth week of the treatment of patients with TOHB showed a much better RPQ score (mean 3.1 vs

6.5 in RPQ-3, and 14.2 vs 29.6 in RPQ-13; The P value for both < 0.001) is depicted in graph 1.

and Graph 2. As a result, the delta score between pre-therapy and the fifth week in the TOHB

group appears to be further down or post-commissioning symptoms tend to be better compared to

the controls:-8.0 vs-4.2 for RPQ-3 (p < 0.001),-23.4 vs-7.2 for RPQ-13 (p < 0.001).
Tabel 1. RPQ scores on patients in research by group, in μ ± SD and N (%)

KETERANGAN: SD standar deviasi. a Uji t pada variabel numerik, Fisher’s Exact pada variabel kategori; b

”Delta” adalah selisih hasil pra-terapi dan minggu kelima.

 Grafik 1. RPQ-3 Minggu ke-5 Grafik 2. RPQ-13 Minggu ke-5

TOHB effect on RPQ score

Tabel 2. Present the results of the regression analysis of the outcome variables of

research outcomes with the provision of TOHB. Each individual's value for all outcome

variables is calculated according to the fifth week result difference before treatment. The use

of "Delta" outcome values addresses the need for adjustments to the research design that

measures the variables repeatedly on each subject. In the outcomes of RPQ-3 and RPQ-13 the

fifth and pre-therapeutic week difference values are the only options for controlling the

dependencies of the measurement results because measurements are only performed 2 times.
 The effectiveness of TOHB in this condition is also seen in the changes in the RPQ

score, both related to the initial symptoms (RPQ-3) and further (RPQ-13) on the CKR. Large

RPQ score reduction for both groups of items is also quite large (-3.80 in RPQ-3 and-16.20 in

RPQ-13) with TOHB administration compared without TOHB.

Tabel 2. TOHB relationship regression Model with RPQ score.

TOHB VS KONTROL
ᵅ β (95% CI) p
Outcome

RPQ-3 -3,80 (-4,78 ; -2,82) < 0,001

RPQ-13 -16,20 (-19,62 ; -12,78) < 0,001

DESCRIPTION: CI confidence interval. Each outcome is a "delta" change in value between pre-therapy

and the fifth week.

DISCUSSION

Effect of TOHB on post-Komosio syndrome

TOHB proved to decrease Intracranial Pressure19 and reduce the pressure of spinal

Serebro fluid (CSS) in patients with acute brain damage,20,21, Improve metabolic activity of

substantia grisea in single-photon emission computerized tomography scan on closed head

22
injuries and improve glucose metabolism after a brain injury.23 In severe head injuries,

TOHB lowers mortality rates and enhances functional outcomes. In chronic brain injuries,

TOHB improves cerebral blood flow, corrects neuropsychological disorders, and enhances

neuropsychological and electrophysiological improvements.

 research reports that TOHB multiple can improve neurological deficits and cognitive
24
disorders in the acute the further chronicle phase, a few months to several years after the

head injury.25-9,30-6 The therapeutic effect of long-term TOHB may be related to a wide range

of improvements, including the activation of angiogenesis and the generation of

neuroplasticity, as well as inducing the proliferation and differentiation of nerve stem cells.

When TOHB (2 ATA for 60 Minutes twice a day for 3 consecutive days) was administered

within 3 hours after the injury in the percussion model of the traumatic brain injury fluid in

rats, there was a significant increase in endothelial cells, neurons and new glia cells at 4 days

after traumatic brain injury 24 . ten Exposure TOHB (2.5 ATA for 60 Minutes to 10 days) can

intensify the neuroplastic response by enhancing axonal sprouting and synapse remodeling,

which contributes to locomotor performance recovery in rats with traumatic brain injuries;27

The TOHB circuit for 40 days (1.5 ATA for 90 minutes each administration) leads to an

increase in vascular density on hippocampal that has undergone a contusio and improved

cognitive function.28 Activation of several signaling pathways and transcription factors

allegedly plays an important role in TOHB-induced neurogenesis, such as Wnt, hypoxia-

inducible factors and cAMP response element-binding.37

In this study the outcome was evaluated by RPQ. RPQ is one of the instruments

commonly used to determine the severity of a collection of symptoms accompanying a mild

38
to moderate head injury. The scoring system was modified from the year 2005 by Eyres.

Individual item scores reflect the existence and severity of post-komosio symptoms. Post-

Komosio syndrome, as measured by RPQ, can arise for various reasons after a head injury

(although not necessarily a direct result). The symptoms overlap with wider conditions, such

as pain, fatigue and mental health conditions such as depression. The questionnaire can be

repeated to monitor the patient's progress over time. There may be changes in symptom
severity, or range of symptoms. Typical recovery is reflected in the reduced symptoms and its

severity in 3 months.

The items are divided into 2 groups. The first group (RPQ-3) consists of the first 3 items

(headaches, feelings of dizziness and nausea) and the second group (RPQ-13) consists of the

next 13 items (Table 3.). The total score for the RPQ-3 item is potentially from 0-12 and is

associated with a collection of early symptoms of post-komosio symptoms. If there is a higher

score in the RPQ-3, a previous re-assessment and more stringent monitoring is recommended.

Tabel 3. Symptom on mild head injuries

RPQ-3
Headaches
Dizziness
Nausea and /or vomiting

RPQ-13
Sensitifitas kebisingan (mudah marah oleh suara keras)
Sleep disorders
Fatigue, easier to get tired
Being irritable,
Feeling depressed or crying
Feeling frustrated or impatient
Forgot, bad memory
Poor concentration
took a long time to think
Blurred vision
Light sensitivity (easily disturbed by bright light)
Double Vision
Restless
 The RPQ-13 score is potentially from 0-52, where a higher score reflects the greater

severity of post-komosio symptoms. The RPQ-13 Item is associated with a group of advanced

symptoms, although the RPQ-3 symptoms of headaches, dizziness, and nausea may also

occur. This set of advanced symptoms is associated with greater impact on participation,

psychosocial and lifestyle functions. Symptoms tend to heal in 3 months. It is recommended

to re-start routine activities gradually during this period, according to the symptoms. If the

symptoms do not heal within 3 months, the reference consideration for a specialist assessment

or maintenance service is recommended.

The results showed that from RPQ-3 and RPQ-13 there was a decline in the score. RPQ
scores, both the initial items (RPQ-3) that relate to the symptoms beginning of the head or
thirteenth injury of the next item (RPQ-13) which contains the further symptoms of head
injury, are no different in the second research group before treatment is performed. But at the
end of the fifth week of the treatment of patients with TOHB showed a much better RPQ
score (mean 3.1 vs 6.5 in RPQ-3, and 14.2 vs 29.6 in RPQ-13; The value P is for both <
0.001). As a result, the delta score between pre-therapy and the fifth week in the TOHB group
appears to be further down or post-compulsionistic symptoms tend to be better compared to
the control group:-8.0 vs-4.2 for RPQ-3 (p < 0.001),-23.4 vs-7.2 for RPQ-13 (p < 0.001).

The effectiveness of TOHB in this condition is also seen in the changes in the RPQ
score, both involving early symptoms (RPQ-3) and further (RPQ-13) in CKR patients. Large
RPQ score reduction for both groups of items is also quite large (-3.80 in RPQ-3 and-16.20 in
RPQ-13) with TOHB administration compared without TOHB. TOHB action against CKR
sufferers resulted in a decreased or improved RPQ score output.

Based on the results of this study TOHB showed positive effects by enhancing the

quality of life in patients with post-Komosio or CKR syndrome at advanced chronic stage,

improving cerebral blood flow, correcting neuropsychological disorders, as well as improving

neuropsychological and electrophysiological repair. Multiple TOHB can improve

neurological deficits and cognitive disorders. This shows the success of intensive TOHB use

as therapeutic modalities in various patients with head injuries.

CONCLUSION

This research has proven the influence of TOHB accelerate the process of healing the

symptoms of Mild Head Injury patients (post-Komosio syndrome).

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