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Use of Hyperbaric Oxygen in Rheumatic Diseases: And Critical Analysis

D.J. Wallace 1,2 S. Silverman.2* J.Goldstein 3,and D. 4

1Department of Medicine Cedar-Sinai Medical Center 2UCLA School of Medicine, Los

Angeles, CA. 3 The Chronic Fatigue Syndrome Institute. Anaheim CA. And 4 Rapid

Recovery Hyperbarics, San Bernardino, CA.

Hyperbaric Oxygen has been used in patients with Rheumatic Disease for many

years with out reports of untoward or unusual complications for a variety of Non

Rheumatic indications. Recent evidence that hyperbaric oxygen inhibits the

actions of certain cyctokins. Acts as an immune doculator and may help cognitive

dysfunction has resulted in a re-examination of its potential role in rheumatic

diseases. A case report of a LUPUS/ Scleroderma crossover patient is presented

whose cognitive dysfunction improved after hyperbaric oxygen therapy. The

history of hyperbaric oxygen and its physiology are related, along with a

focused review of its effects on the immune and central nervous systems. Areas,

which might warrant further consideration by Rheumatologists, are outlined, as

well of areas of concern.

Keywords: hyperbaric oxygen: Scleroderma: rheumatic Diseases

Introduction:

Hyperbaric Oxygen Therapy is defined as the subjecting of patients to pure

oxygen breathing at ambient temperatures, which are greater than normal

atmospheric pressure.

Although concepts of hyperbaric oxygen therapy were first employed in 1662, its

modern use other than for decompression dates from 1956 when hyperbaric oxygen

was used to perform cardiac surgery in Holland 1 . Mechanically, the most common

applications of hyperbaric oxygen are to dissolve air or gas emboli and treat

divers with " bends " or decompression illness.

New insights into the biochemical and immune interactions of hyperbaric oxygen

have increased interest in its potential applications over the past decade. The

United States Medicare System has approved hyperbaric oxygen for 13 indications

ranging from acute Carbon Monoxide intoxications, Gas gangrene, and

osteroradionecroisis to acute arteriolar insufficiency. Over the last 20 years,

patients with a variety of conditions, especially Multiple Sclerosis, have

reported cognitive improvement after undergoing hyperbaric oxygen. One Lupus/

Scleroderma crossover patient, whose case is reported here, underwent hyperbaric

oxygen therapy specifically for cognitive impairment. And experienced subjective

and objective improvements. Her case is presented and our concepts of hyperbaric

oxygen and the immune and central systems are reviewed.

Case Report:

A 53 year old Caucasian Woman flight attendant who was in her usual state of

health in 1979 when she underwent Thyroidectomy and inadvertent

parathyroidectomy for Graves disease. In February of 1980, her Heyer Schulte

saline breast implants (place in 1977 for cosmetic purposes) were replaced with

-Uphoff Silicone prostheses. She was well until 1986 when she presented to

UCLA Medical Center with subcutaneous arthritis, Raynaud's phenomenon,

Sclerodactyly, inflammatory arthritis, and erythermatous rashes. A work-up

demonstrated an ANA of 1:40 (speckled), elevated sedimentation rates (averaging

in the high 30's) and persistently decreased IgA levels. She was diagnosed as

having a Lupus/ Scleroderma crossover. Although the possibility of Eosinophilic

fascuiitis was considered. (It was ultimately ascertained that she occasionally

took L-troptophan to sleep after long fights.) No disease modifying therapy was

given: supportive diuresis and not steroidal anti- inflammatory agents were

prescribed. Over the following 7 seven years, Her ANA rose to 1:1280

(homogeneous) a positive IgG anticardiolipin antibody was found and her course

was complicated by percarditis and supraventrocular tachyarrhythmias. The latter

of the two items were felt to be suggestive of cardiac sclerodrema: anti RNP was

negative and her inflammatory arthritis subsided. CD3 levels. B cell and natural

killer cell values do not change. Similar findings have been found in mice in

two separate studies. 9.10 Interestingly, the administration of Immunoglobulin

production by spleen cells 9 Long terms hyperbaric oxygen delayed the

development of Proteinuria, facial erythema, and lymphadenopathy in MRI/ 1pr.

Mice. Iamoto et al showed that hyperbaric oxygen has immunosuppressive

properties modulated by decreasing interluekin 1 and prostaglandin E2

production, but interleukin 6 in production was not altered. 11

How does Hyperbaric Oxygen Affect the Central Nervous System?

Studies of hyperbaric oxygen on the central nervous system show that at tensions

of 1.2- 1.5 atmospheres absolute (ATA), it decreases blood flow by 1-20% (mean

of various studies is about 10%), 2 other physiologic changes occur. These

include greater permeability of the blood brain barrier to medications and

increased oxygen tensions tissues that far outweigh the net effects of mild

vasoconstriction. The deformability of erythrocytes is increased resulting in

improved transportation in the microvasculature circulation and lactate removal.

12 Hyperbaric oxygen stimulates the metabolism of nerve cells deprived of

oxygen. As early as the 1960's, Meijne reported cognitive improvement in

patients to performing mathematical calculations and demonstrated increased

typewriter skills after hyperbaric oxygen 13 An area of controversy among

Hyperbaricists concerns the possibility that once 1.5 ATA is exceeded, anaerobic

metabolism is favored and thus cognitive do not improve as well as they would at

lower pressures. Di Sabato et al 14 performed a controlled study (with Sham

hyperbaric controls) on patients with cluster headaches. The dramatic

improvement was attributed to vasoconstriction, decreased edema, increased

serotoin synthesis, and decreased cerebral hypoxia. Additionally, in the central

nervous system hyperbaric oxygen decreases adrenaline and monoamine oxidase

levels as well as promoting axonal regeneration 15.

Hyperbaric Oxygen for Multiple Sclerosis and other autoimmune diseases:

As hyperbaric oxygen decreases demyelination from per-vascular edema, over 6000

patients with multiple sclerosis have undergone this therapy in the past 10

years. A published trial by The New England Journal of Medicine Suggesting

improvement with hyperbaric oxygen in 40 patients in 1983 stimulated

considerable interest. 16 However, it was evident that even though hyperbaric

oxygen increased helper T lymphocyte levels, patient liked the treatment and

reported subjective improvements (especially in the sense of well-being,

cognitions and bladder function), Four separated placebo -controlled double

-blind trials failed to demonstrate any objective benefits of using the Kutz

Disability status Scale or any other parameters 17-20 This was also confirmed in

a 22 institution multicenter registry 312 patients followed for 2 years. 21

Occasionally patient with other rheumatic syndromes and associated complications

have been held to respond to hyperbaric oxygen. Aseptic necrosis complicating

system lupus, for example, appears to be worthy of greater scrutiny. Abstracts

and presentations at seminars and meetings of hyperbaric oxygen claim benefits

for pneumatosis cystoid intestinal in sclerodrema, livedo reticularis with

Vasculitis and Raynaud's phenomenon. Articles have appeared advocating

hyperbaric oxygen for Crohn's disease and cyclophophadmide-associated

hemorrhagic cystitis

How save is hyperbaric oxygen?

Hyperbaric Oxygen is generally quite safe, but serious complications can

occur.24 Absolute contraindications to hyperbaric oxygen include pregnancy,

underlying malignancy, untreated PNEUMOTHORAX, concomitant therapy with

doxorubicin, cis-platinum, or disulfiram. Special considerations need to be

taken into account if the patient has upper respiratory tract infections or

chronic sinusitis (which make clearing of the ears and sinuses problematic) low

seizure thresholds (with high fevers or epilepsy, emphysema with CO 2 retention

(which suppresses breathing). And congenital spherocytosis (hempolysis can

result) The most common complication of hyperbaric oxygen is barotrauma to the

ears and sinuses caused by pressure changes, which has been reported in about 5%

of the cases. Occurring in 0.1- 5% of the patients are hypersensitivity

reactions confinement anxiety, central nervous system oxygen toxicity, pulmonary

oxygen toxicity and temporary changes in eyesight. To minimize risks, patients

are advised to have an ear, nose and throat examination by the treating

Physician before therapy, not to drink alcohol or take any medication for 4hours

prior to treatment, and to wear 100% cotton clothing.

Is there a potential role for hyperbaric oxygen in Rheumatic Diseases?

Very little is known about the influence of hyperbaric oxygen on the immune

system. Animal models of autoimmune disease and normal mice are conductive to

hyperbaric oxygen studies. Hyperbaric oxygen might be useful in combination with

other therapeutic modalities. Further study is needed in these areas before

proceeding to human trials. Nevertheless, anecdotal testimonials that hyperbaric

oxygen helps people think more clearly should be taken seriously and ultimately

subjected to a prospective trial.

Systemic lupus erthematosus (SLE) is an autoimmune disorder that affects several

hundred thousand Americans. Nearly half manifest in similar cognitive deficits

that do not respond to CORTICOSTEROIDS. 26 In the past few years, the

development of single photon emission computerized tomography (SPECT) has shown

hypoperfusion abnormalities bitemporally and bifrontally in patients with SLE

and incidentally, with fibromyalgia/ Chronic Fatigue syndromes. 26-29

Hyperbaric Oxygen is a well -characterized, old technology whose immunodulatory

properties and effects on cognition have never been adequately studied. Although

relatively expensive, this reasonably safe procedure might have potential

heretofore-unrealized applications to the patients with rheumatic disease.

Permission to print

Reference: 1-29. Upon request.