After 22 years in the United States Army, Mike Jackson had become used to living with a number of physical and mental ailments. He hadn’t felt one of his feet for more than a decade, tinnitus was causing a constant ringing sensation in one ear and, like many veterans, he was suffering from post traumatic stress disorder (PTSD), memory loss and depression.
“My wife said that she had to tell me something two or three times before it would get into my head and I could remember it. It’s totally different. I can remember things from back when I was a kid now,” Jackson said. “I mean, this is … to me, this is big-deal stuff. I don’t understand how it works, I just know that it’s working.”
Jackson was referring to hyperbaric oxygen therapy (HBOT). Long used to treat open wounds, infections and decompression sickness, HBOT utilizes a highly pressurized chamber that allows patients to breathe in several times more oxygen than is possible under normal atmospheric conditions.
After a few sessions, Jackson said, he had feeling in both of his feet. The ringing in his ears had stopped, and the flash points and negative outlook he associated with his PTSD were gone.
“The biggest thing is I appreciate life now,” Jackson said. “I played Army for 22 years. I wasn’t happy unless I was in the Army. When I lost that … when they medically discharged me. I lost my identity, you know? I’m starting to have an identity again.”
While his physical improvements aren’t controversial, Jackson’s cognitive improvements are — at least when it comes to treatments the U.S. departments of Defense (DOD) and Veterans Affairs (VA) are willing to pay for.
The U.S. Food and Drug Administration (FDA) only approves HBOT for a handful of mostly physical conditions, so using it to treat PTSD or any traumatic brain injury (TBI) is considered an “off label” use by many private insurers and one the DOD and VA won’t cover.
Integrated Pain Management of Alabama (IPMA), a pain clinic in West Mobile, is the only facility in the state designed to to treat those types of brain injuries using HBOT. It was opened in 2013 by Dr. Lloyd Manchikes, a board-certified anesthesiologist also qualified in HBOT medicine.
Together with hyperbaric technologist Pat O’Brien, Manchikes has been offering free treatment to veterans like Jackson, using the proceeds from his pain management practice to offset the costs. They’ve also recently created a GoFundMe page to raise money for the same purpose.
With many veterans living with pain, emotional and mental distress, and addiction, O’Brien said an effective treatment such as HBOT is a much better alternative to numbing the symptoms of veterans who are suffering when they return to civilian life.
“It’s not a pill. It’s an actual treatment, and what they get from this they will have for the rest of their life,” O’Brien said. “It’s not me trying to retrain you how to think, it’s an actual treatment. If we can save one person, it’s better than nothing at all.”
However, because of the many complicated insurance issues, Manchikes and O’Brien have also spent years pushing for a change in the VA’s policy on HBOT as a treatment for TBI.
So far, those efforts have been unsuccessful.
‘Injured brains’ and ‘a suicide epidemic’
While IMPA’s operation is unique in Alabama, dozens of clinics are performing similar pro bono work across the country. Recently, IPMA joined the TreatNOW Coalition, which includes 30 similar clinics nationwide dedicated to treating veterans suffering from TBI and PTSD in hopes of stemming an “epidemic of suicide” that’s plagued U.S. war veterans in recent years.
According to the VA, an average of 20 veterans committed suicide every day of 2014, and another 45 attempted and failed. Adjusting for age and gender, the risk for suicide is 21 percent higher for veterans than civilians.
Manchikes said there’s a correlation between those rates and the number of veterans suffering from traumatic brain injuries, adding he has treated multiple TBI patients who’ve experienced suicidal thoughts — “enough brain injury in 30 years to understand the misery behind [it].”
Dr. Robert Beckman, a Vietnam veteran who coordinates TreatNOW’s national network of hyperbaric clinics, told Lagniappe concussions, TBI and PTSD are prevalent among veterans because of their higher exposure to “blast injuries” when they are deployed.
“When you really get blasted, it’s like throwing molasses into the inner workings of a computer,” Beckman said. “Cell death can follow, and you can just lose everything — executive function, memory … and then depression isn’t far behind.”
Beckman said there’s no doubt brain injuries in the veteran population contribute to their elevated risk of suicide. In a paper he published on the subject, Beckman wrote that “nearly 25,000 veterans may have been misdiagnosed” by the VA who had some type of TBI, because they are often diagnosed with “only PTSD.”
“Couple those numbers with the 325,000 service members diagnosed with ‘only PTSD’ that may be the secondary outcome of TBIs caused by blast, along with the 345,000 acknowledged TBI diagnoses, and the numbers of untreated brain injuries are staggering,” he added.
So far, TreatNow claims to have recorded “over 2,350 success stories” in cases treating TBI and PTSD with hyperbaric oxygen therapy, though those aren’t exclusively veterans.
High-profile suicides by athletes such as ex-NFL player Junior Seau and former wrestler Chris Benoit — both of whom showed signs of chronic traumatic encephalopathy after death — have a growing number of active and retired athletes looking into HBOT, with some claiming to have found similar relief.
Former University of Alabama and New York Jets quarterback Joe Namath is putting his own money into HBOT research and has established the Joe Namath Neurological Research Center in Jupiter, Florida.
Mobile resident Edward Davis knows firsthand TBI doesn’t only affect soldiers and professional athletes, though. In 2014, Davis became septic after medical complications caused to E. coli to enter his bloodstream. The result was a five-week coma.
By the time he regained consciousness, Davis had lost his job as an engineer, along with most of his motor functions and his ability to speak. He said he had “just enough brainpower to know [he] was screwed.”
“I’d get aggravated because I couldn’t tell anybody what I wanted, and I couldn’t eat. I knew my hands were here, but it was like my fork just wouldn’t go to the plate,” he said. “It almost ruined my life. I went from making $120,000 a year to $0 in one day. I mean, we lost everything.”
Two months later, Davis was living with his mother and still struggling to perform basic tasks. He believes he had two choices: “shooting [himself] in the head” or “not quitting.” Part of Davis’ road to recovery was found at IPMA when he came to the clinic seeking treatment for shoulder pain.
At the time, Manchikes recommended Davis try HBOT to address his cognitive issues, and within weeks he was walking and talking again. Now Davis manages the clinic’s IT and computer systems while finishing classes to re-earn his engineering degree.
“As an engineer, they get kind of funny about brain damage,” Davis joked. “I scored a 127 on my IQ test, which I thought was going to take a big hit because I was down to my baseline functions. I mean, my heart was beating, and that was about it.”
A session of HBOT is often called a “dive” — a name taken from its similarities to scuba diving. In a hyperbaric chamber treating brain injury, the atmospheric pressure is typically one and half times greater than normal.
Those dives can last anywhere from an hour to 90 minutes. Manchikes said his patients typically go through some 40 dives during treatment for TBI. At $250 per dive, he said, a full treatment usually costs anywhere from $6,000 to $10,000, depending on the progress.
Critics of HBOT therapy — including those within the DOD and VA — have dismissed improvements in the past as merely a “placebo effect,” but Manchikes said physicians can measure a patient’s improvements in blood flow scans taken of the brain.
“You’re healing the anatomy, and then the software comes along behind it,” he said. “In a lot of cases, you’re back to where you were — cells wake up, blood vessels get flowing between areas where they had previously been disrupted, and what can be saved is saved.”
However, not everyone agrees.
Manchikes and Beckman have both lobbied on behalf of HBOT research for the treatment to be covered under DOD and VA health benefits, and both have described a consistent mantra in Washington of people saying, “It isn’t FDA approved.”
Indeed, VA spokesperson Terrence Hayes gave a similar response when Lagniappe asked about the lack of support for HBOT, though he did commend IPMA for “offering assistance to veterans.”
“It is important to note the [FDA] does not recognize the use of hyperbaric oxygen for treatment of brain injury, and has warned that patients may be unaware that its safety and effectiveness has not been established for brain injury,” Hayes wrote. “The absence of FDA clearance for the proposed indications, potential safety risks, coupled with limited evidence of sustained benefit, precludes VA from endorsing [its] use for TBI at this time.”
Beckman has taken issue with that particular objection for a number of reasons, but mostly because he claims there is no FDA-approved treatment for TBI because the procedures, computer applications, therapies and drugs the VA does cover are also used “off-label.”
According to Beckman, the majority of brain injuries aren’t treated at all, their symptoms are only masked — often with prescriptions for treating pain, anxiety and depression, drugs that come with their own risks including “a dozen that are ‘black box’ labeled, warning of the risk of suicidal ideation.”
That leaves what Beck says is an obvious question: “Why do the DOD, VA and Army deny HBOT to the injured?”
Though he said there are multiple answers to that question, Beckman believes many are rooted in the financial interests of the institutions and corporations perpetually researching the problem and potential solutions, as well as those of the DOD, which can’t treat soldiers for TBI if no treatment exists.
“I know this is hard to understand as a layman: Guys are committing suicide, why don’t we try and stop it?” He said. “But that’d be interrupting business as usual inside the military and the VA as well as the vast amount of money that’s dedicated to research instead of treatment.
“There’s no patent on oxygen and no profit in fixing the problem,” he added.
Momentum for change
To say the least, Manchikes and O’Brien’s efforts to get the VA’s policies changed on the federal level have left a bad taste in both their mouths.
Manchikes said he’s personally met with the staff members from many local representatives’ offices and with several members of congressional committees overseeing veterans’ health care programs. He’s says he’s been frustrated with their responses.
“They don’t work for us,” Manchikes said. “We’ve been to [Sen. Richard] Shelby. Shelby’s not around. [Sen.] Luther Strange is unavailable. [Attorney General] Jeff Sessions has moved on.”
Though Manchikes says he had trouble getting U.S. Rep. Bradley Byrne’s staff to follow up with him, Byrne has taken some direct action on the issue. He’s also no stranger to criticizing the VA, recently describing it to Lagniappe as “a huge and bloated bureaucracy.”“I have called on the VA to further evaluate hyperbaric oxygen therapy as a way to treat veterans with PTSD,” Byrne wrote via email. “I think we should be considering every tool at our disposal when it comes to helping veterans get the help and care they need.”
Byrne was also one of 13 House members who signed a letter to the VA in 2015 urging the expansion of veterans’ access to HBOT under their VA benefits. It said HBOT was valuable as a treatment for PTSD and TBI “without the need for prescription medication” and could address the “overmedication of veterans” that “plays a direct role in [their] rate of suicides.”
The VA declined that recommendation, however, stating that three separate DOD-funded studies were unable “to demonstrate any positive effects” of HBOT in the treatment of brain injuries and PTSD — concluding “the risks of the procedure outweigh possible benefits.”
Many proponents of HBOT have disputed the accuracy of those past studies, and Beckman has often claimed the VA or DOD’s direct oversight presents a conflict of interest he compared to “cigarette companies sponsoring research into the links between smoking and cancer or asking the NFL whether concussions lead to brain damage.”
Still, the VA isn’t entirely opposed to researching HBOT further. This week, Hayes said the VA would be partnering with DOD on upcoming research into its effectiveness in treating PTSD — research that will be conducted during a three-year trial involving 150 active-duty service members.
In the meantime, TreatNOW and physicians around the country who believe the debate over HBOT is already settled are continuing to treat veterans who aren’t finding relief elsewhere. Manchikes said the positive results IPMA has recorded are “across the board.” He wants to see the work continue.
“I just want to get paid for doing this so we can keep doing it,” he added. “We’re giving it away for free, but the oxygen alone costs at least $1,800 a month, and we’re not running full steam.”