Controversial Treatments, Myths Debunked and Lessons Learned
With the push to find a “cure” for the signature injuries of the Iraq and Afghanistan wars, hyperbaric oxygen (HBO) treatments have been highlighted as a potential solution to address post-traumatic stress disorder (PTSD) and concussion from traumatic brain injury (TBI).
Today’s issue of JAMA Internal Medicine includes a commentary [i] that Dr. Charles W. Hoge [ii] and I were invited to submit on a new study of HBO for TBI.
The commentary responds to the results of a clinical trial [iii] that reports significant improvements from HBO in post-concussion symptoms and also other, secondary outcomes from stress and trauma (which I call the trauma spectrum response, TSR).
However, a major disappointment for proponents of the treatment is that there were no differences between HBO and a sham procedure in which patients underwent the same ritual of HBO but without the oxygen added. In fact, symptoms for the secondary TSR outcomes were better in those who received the sham treatment than the actual HBO treatment.
So what’s the takeaway of this study, which produced significant symptom improvements in both the sham (placebo) and HBO intervention groups? If the added oxygen is not what is producing the benefit, what is?
For me, the most important lesson from this study is that good intensive medical care and the process embedded in the ritual of that care is the most important thing we can do for healing our veterans from TBI. It is the intention, inter-personal interaction and meaning that good medical care imparts that gets people better.
These are the components of an optimal healing environment.
That’s what is working.
I argue that this study can be a positive one for the field of post-traumatic stress and traumatic brain injury if understood from the right perspective—that of a healing environment. By shifting our focus from seeking a “magic bullet cure” to a holistic clinical approach we can optimize healing factors and provide the most help for patients and our veterans.
It’s not the placebo that makes you better; it’s the meaning and context behind the care interaction that makes you better.
The following are the underlying mechanisms of the placebo engine that make it run:
- enhanced expectancy – judgments our brains make subconsciously when receiving care
- conditioning – an unconscious response to a ritual or signal paired with a healing event
- an authoritative context of care – sometimes called the “white coat effect,” this refers to the tendency of patients to respond better to treatment based in the settings and rituals associated with healing
- social reinforcement – the individual reaction to social behaviors that reinforce the above
All of these factors are part of the delivery process for HBO, with or without the oxygen. What is powerful is that these factors can lead to healing.
If we focus on the goal of increasing quality of life and decreasing the pain and stress that our warfighters are facing, their journey to recovery will become less about an intervention and more about optimizing their internal healing processes.
Our view of holistic care is one that keeps in mind all aspects of the Optimal Healing Environment framework; from tending to the internal needs of a person to their interpersonal relationships to behavioral components and finally the external environments in which the patient lives, works and receives care.
So while it’s essential to continue to search for the “magic-bullets” and “cures,” it’s equally important to explore the factors that we know lead to healing and optimize them as much as possible.
Unfortunately, we don’t know enough about these factors to fully apply them. If we want to help our veterans now and optimize any new cures that come along in the future, we need to spend more time and resources understanding healing and applying it in all aspects of health care.
[i] “The Ritual of Hyperbaric Oxygen and Lessons for the Treatment of Persistent Postconcussion Symptoms in Military Personnel.” JAMA Intern Med, Nov. 17.2014 epub ahead of print
[ii] Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland