Hyperbaric Therapy — A Vastly Underused Treatment Modality
STORY AT-A-GLANCE Dr.
Jason Sonners, author of the book, “ Oxygen Under Pressure: Using Hyperbaric Oxygen to Restore Health, Reduce Infiammation, Reverse Aging and Revolutionize Health Care ,” started out as a chiropractor. His passion, however, is hyperbaric oxygen therapy (HBOT), which is the focus of his Ph.D. studies at the University of Miami.
While commonly used to speed up stubborn wounds and tissue infections, hyperbaric medicine can also be helpful in the treatment of infectious diseases such as COVID. It's also enormously useful for stroke patients. I can't think of a more effective intervention than to get the stroke patient into a series of hyperbaric treatments as quickly as possible.
HBOT for General Health and Disease Reversal
Every cell in your body, with the exception of your red blood cells (which have no mitochondria that require oxygen), requires oxygen to create energy. Many chronic diseases of the modern world involve decreased mitochondrial function, increased systemic infiammation, and an inability of cells to generate the required amounts of energy for optimal function. “We use hyperbaric oxygen, traditionally, for these terrible and severe conditions,” Sonners says. Unfortunately, it's typically a last resort, literally right before an amputation surgery or as a life-saving mechanism for somebody with carbon monoxide poison or air gas embolism.
“So, we only think about it, traditionally, to help save the life or limb ofsomebody in a really severe condition, but the mechanisms that are working forthose folks are very similar to the reasons that you and I might consider usinghyperbaric oxygen:For upregulating the oxygen levels inside your body, which will help reduceinfiammation, increase mitochondrial function ... and thereby increasing theenergy that those cells are able to generate ...”
HBOT for Chronic Diseases
Sonners' goal is to expand the use of HBOT from the acutely life-threatening issues like gangrene to more chronic conditions, such as autoimmune and neurodegenerative diseases.
“My thought process is that the mechanisms of action of hyperbaric are thesame whether we're talking about gangrene, radiation burns and osteonecrosis,or TBI [traumatic brain injury], concussion, maybe MS [multiple sclerosis] andpost-stroke.If we really get a mastery of the mechanisms of action, we can start to applythose mechanisms across the board. Clinically, we've seen hyperbaric work forso many of these other chronic illnesses ...So, if we could really home in on those mechanisms and understand thembetter, and then get a better feeling for what time and pressure settings werequire in order to get those mechanisms to kick in, then we can really, withmore confidence, apply this therapy to these other conditions and have moreconsistent results in doing so.A lot of the work I'm proposing to do is tagging onto some of this work inregenerative medicine, where they were looking at the collagen, fibroblast andstem cell response to hyperbaric. A study came out in 2020 on telomeres, andlooking at this potential, upwards of 20% increase in telomere length, especiallyin certain immune system cells.I want to build on that knowledge base, so what I'm doing is I'm creating a studythat's going to have a lower-pressure group and a higher-pressure group, andwe're going to be looking at a whole cytokine panel, so we can understand themechanisms of the anti-infiammatory side.We're going to have a methylation panel so that we can start looking at theepigenetic effects of hyperbaric. We're going to have a telomere component,similar to the telomere study that was done a year and a half ago.And we're going to start comparing all of those metrics across roughly a three-to six-month timeframe of treatment, and over two separate pressure settings,to better understand which pressures are getting which effects, and again, whatperiod of time should we be expecting before we get the results that we'relooking for?”
Research Underway
On the low end, Sonners will be using 1.3 atmospheres (4.2 PSI) at 100% oxygen, and on the high end, he'll use 2.0 atmospheres (14.7 PSI) at 100% oxygen. All patients will use hard chambers at two different pressures. The lower pressure group will be at 4.2 psi, which is the same as soft chamber pressures.
“There's nowhere near the amount of research in soft chambers as there are inhard chambers,”
Sonners says
. “The overwhelming majority of research is doneat that 2-atmosphere range, which is why I'm choosing that as the upper end ofthe research that I'm doing in the soft chamber research.There is definitely some [research] on sports recovery. There's actually someongoing studies right now on hyperbaric for stem cell use that we're waiting for.In some cases, 1.3 [atmospheres] has been used as the sham group, opposedto a treatment arm in the research. Maybe the study team really thought that1.3 wasn't going to have an effect and it's a legitimate sham ...I'm not sure, but there are some great studies. There's a study that was done oncerebral palsy (CP) and 1.3 was used as the sham group ... In this particularstudy, with 1.3 being the sham group, there was also a ... control group that gotno hyperbaric at all.Within the sham group, there was significant improvement on the metrics theywere measuring. Then they had a 1.5 [atmospheres at] 100% oxygen, which alsohad a good improvement and then, a 1.75 [atmospheres at] 100% oxygen, whichhad even a greater improvement.The issue in the study was that while all three of those groups improved, therewas no statistical difference or enough of a statistical difference between the1.3, the 1.5 and the 1.75. So, the conclusion of the study was therefore thathyperbaric does not work for CP, although all three of those groups hadsignificant improvement.So, because the sham group was not considered a treatment, that was theconclusion of that study. Now, the natural consequence of that should havebeen redoing the study and creating a different level of what the sham and thetreatment arms ought to be, but that was never redone.So, as a result, there's this study with results that say hyperbaric does not workfor CP. Meanwhile, clearly, what it means is we need more studies. It's just thatstudies are expensive. They're very time consuming and you really have to havea large interest in trying to come up with the right answers to put forth the effortand time and money to get that kind of work done.”
Mechanisms of Action
If you breathe 100% oxygen under pressure, it's intuitively obvious that you're going to deliver more oxygen to your tissues. That's one clear mechanism, but it's not the only or even primary reason for most of the benefits of hyperbaric therapy. Evidence suggests part of the benefit might be related to the degeneration of a molecule called hypoxia-inducible factor alpha (HIF-1 alpha), which is generated when you lower the pressure. The pressure is high inside the chamber, and is lowered when you exit the chamber and enter the normal atmosphere. That means some of the benefit might actually be occurring when you get out of the chamber. Sonners explains:
“We don't have an exact number right now, but roughly half of the treatment isoccurring while you're in the chamber, being exposed to the pressure, beingexposed to the oxygen and literally accumulating a surplus of oxygen becauseof the therapy itself.The other half of the therapy is when you get out of the chamber, as that oxygencan no longer stay in solution. It literally starts trying to bubble out of solution.As that happens, it's not inert, it's actually very active. So, as it's coming out ofsolution, it's interacting with all of our cells.As a result, it's triggering a massive cascade of events, cellular communicationthat seems to stimulate multiple series of regeneration and anti-infiammatory[events], even within the reactive oxygen species themselves.When we look at the first part, which is the dosage of oxygen a person isgetting, and that's measurable, you could say, ‘Here's a person, they were in achamber, they were at this pressure, breathing this percentage of oxygen forthis amount of time,' and you could literally calculate the theoretical dose ofoxygen that person was exposed to and should have been able to absorb.We've kind of just stayed in that mindset for all these years. [However], therewas a great paper out of Israel called ‘The Hypoxia-Hyperoxia Paradox,' andwhat they're saying is we know that there's amazing benefits of hypoxiaactually.”
Benefits of Relative Hypoxia
Some of these benefits include the stimulation of HIF-1 alpha, stem cell responses, collagen responses and the angiogenic responses. For these reasons, Sonners views hyperbaric as an anabolic therapy — a therapy that stimulates vitally important growth and repair, as growth factors such as VEGF (vascular endothelial growth factor), and BDNF (brain derived neurotropic factor) are both stimulated. Again, these growth factors are not stimulated by the hyper-oxygenation. They're a result from the hypoxic component, the process your body goes through as the oxygen is leaving your body.
“The important thing to note is that once you've accumulated all this extraoxygen, your hyper-oxygenation component, as that oxygen is leaving yourbody, you're never truly hypoxic,”
Sonners says,
“but the cell signaling factorsthat respond to traditional hypoxia are also seemingly responding to thisrelative hypoxia.If you look at that paper [‘The Hypoxia-Hyperoxia Paradox'] ... it seemed todelineate this. With hypoxia alone, you will still get VEGF, which means you'llstill get a lot of angiogenics, the rebuilding of the endothelial lining, the creationof a new micro-circulation bed, all this capillary regrowth will happen fromhypoxia.You'll get these stem cell releases, this potential for increase in the regenerativenature of cells. You'll get this increase in the HIF-1 alpha. But if you'rechronically hypoxic, you're also going to get a downregulation of sirtuins[longevity proteins] and you're going to get a downregulation of mitochondrialfunction.Sirtuins could play a great role in things like cell cycle life, getting cells out ofcellular senescence — kicking them back into active life — or apoptosis, killingthat cell so that we can replace it with a new stem cell, or even the genetic andepigenetic repair mechanisms. A lot of that has to do with sirtuins, so we don'twant to downregulate those. We want to upregulate those.”
So, to clarify, with HBOT, you get the benefits of hypoxia with none of the downsides. Rather than inhibiting sirtuins, which are important for health and longevity, you actually get an upregulation of sirtuin activity. It also upregulates mitochondrial function and boosts mitochondrial replication, which the complete opposite to what happens in true hypoxia.
What About the Free Radical Component?
Without any doubt, HBOT is a type of oxidative stress, but it doesn't have the adverse effects you'd expect. Sonners explains:
“There was a great paper done by Dominic D'Agostino and Angela Poff, back in2017 or 2018, specifically looking at the reactive oxygen species or the freeradical component of hyperbaric oxygen. What are the benefits orconsequences as we upregulate, as we increase the amount of oxygen into thebody?As the cells and the mitochondria start to uptake that oxygen, producing moreenergy, there is a natural consequence where this byproduct of free radicals arereleased as a part of normal cellular respiration. Excess free radicals isobviously consequential to cell membranes, lipid peroxidation and proteindegradation.It could destroy cell membranes, mitochondrial membranes, nuclearmembranes, genetic material ... At the same time, it's a normal response tocellular respiration and our bodies have their own intrinsic mechanisms fordealing with some of this excess free radical, things like the superoxidedismutase, catalase and glutathione pathways.So, there seems to be a distinction that we should make. One is that some ofthe free radicals our bodies are exposed to come from the outside world in.Radiation, smoking, air pollution, the list goes on and on. So, we need to have arobust, intrinsic ability to tolerate these free radicals with our own antioxidantsystem.But in excess, we could be getting too much free radicals and we could bedepleting our own systems, in which case supplementation should certainly beconsidered and used. On the fiip side, we look at hyperbaric oxygen as this toolthat theoretically has all these great effects, but one of those consequenceswould also be this increase in free radical exposure.There seems to be a very big delineation between a body that's exposed to freeradicals from the outside world, versus a body that is exposed to free radicalsthat it's creating on its own.One of those distinctions is that through the use of hyperbaric oxygen, evenwithout supplementation, and the increase in free radical production frommitochondrial ATB production, the body itself — assuming it has the right rawmaterials — will actually increase its own superoxide dismutase, catalase andglutathione pathways.This would No. 1, help make you more resilient to hyperbaric oxygen, but No. 2,would also help make you more resilient to all the other free radicals that you'repotentially exposed to in your environment.So, I would say two things. One, especially with patients who are a little bit morefragile when it comes to oxidative stress, those people, I would tend to not overoxidize to begin with, so I might start at a gentler hyperbaric protocol with them,and I'm likely to want to start quickly upregulating their own system, getting theright supplementation for improving their intrinsic antioxidant systems ...Then, as their system improves their tolerance for reactive oxygen species, wemay not need as much of that, or if we're going to be using high dose hyperbaricoxygen for a period of time, we might use things like certain SOD precursors, ormolecular hydrogen.Through conversations with you, it has become one my favorite antioxidantsthat we use. Between 45 minutes to an hour before [hyperbaric treatment], we'llstart loading people with the molecular hydrogen as a mechanism to reduce theconsequences. There are benefits, in other words. Reactive oxygen species onits own also helps stimulate hormone balance and helps stimulate cell repair bythemselves. So, there has to be this balance.We don't want to quelch all the free radicals because free radicals are a veryimportant signaling molecule for so much cellular activity and at the same time,we want to be aware of the fact that hyperbaric does increase that, and we wantto make sure that we're not over-exposing somebody.”
HBOT Functional Medicine Course Now Available
Sonners also reviews the curriculum he developed for the International Board of Undersea Medicine. The IBUM has been certifying people in hyperbaric medicine for 25 years, and the curriculum Sonners created has been taught as a functional medicine hyperbaric course for clinicians for the past year.
“A big push for me, and even for the research I'm doing, is to help createawareness that gets more doctors excited about [HBOT], that want to actuallyuse it in their practice,”
Sonners says.
“So, this has been an attempt to reallyimprove the education so that people aren't just going to hyperbaric courses tolearn about wound care.We needed courses to help practitioners like myself or other people interestedin the regenerative side to be able to learn how to apply it that way. So, we nowhave a course that I teach a few times a year to get people on the same page.The majority of this last year, other than getting through school and writing thethesis, has been developing and promoting that course. I think we've certifiedabout 125 to 150 practitioners and technicians specifically on the functionalmedicine side of hyperbaric use ...At this time, I still see a pretty big mix between soft chamber use and hardchamber use. A lot of those doctors are either Dos, MDs, chiropractors ornaturopaths, getting into more of a functional medicine base, just looking forother natural approaches to the things they are treating.Hyperbaric supplies the body with a fundamental ingredient and it's sonecessary for cellular performance. It just seems to make sense to startimplementing a tool and a modality like that into a setting where you're trying toreduce infiammation, you're trying to improve energy production cellularly.”
HBOT Has at Least 100 Indications for Use
While the list of potential uses for HBOT is extremely long, in the U.S., the Food and Drug Administration has approved and most insurance will pay for HBOT for the following 14 conditions: Air or gas embolism Carbon monoxide poisoning Clostridial myositis and myonecrosis (gas gangrene) Crush injuries, compartment syndrome and other acute traumatic ischemia Decompression sickness Arterial insuficiencies, such as central retinal artery occlusion Severe anemia Intracranial abscess Necrotizing soft tissue infections Osteomyelitis Delayed radiation injury (soft tissue and bone necrosis) Compromised grafts and fiaps Acute thermal burn injury Idiopathic sudden sensorineural hearing loss In terms of conditions that can benefit from HBOT, I would certainly add stroke, TBI, heart attack, anytime there's post ischemic reperfusion injury, and most neurodegenerative conditions. Internationally, there are about 100 recognized indications. While that might make it sound like a magical cure-all, it's important to remember that it doesn't cure anything directly.
The main effect of hyperbaric is really achievedthrough the cumulative effect and the increasing anddecreasing — the wave of hyper-oxygenation back tonormal oxygen levels — creating that hyperoxia-hypoxia type paradox. ~ Jason Sonners1
What it does is provide your body with a foundational nutrient, oxygen, that virtually all cells require. HBOT supplies your body oxygen in a surplus, creating an excess reservoir of oxygen to improve that function. That's why it can help improve such a wide variety of health conditions. Even autoimmune diseases such as MS, lupus and rheumatoid arthritis, just to name a few, may benefit, Sonners says. A whole other category of potential use would be wellness, longevity and regenerative-type therapies.
“We're just applying the tools slightly differently to help match the intensity ofthe therapy to the severity of the condition. We can utilize the principles of gasexchange in various ways to help so many different types and various types ofconditions,”
Sonners says.
“One condition or subclass that we talked about it in the beginning is, from theimmune system standpoint, upregulating your ability to fight infection byincreasing white blood cell activation through the reactive oxygen speciesmechanisms. We use it for anaerobic infection, bacterial infections all the time.One of the main reasons that hyperbaric works in those severe conditions isthose bacteria are anaerobic. They don't live in high oxygen environments.So, we know that putting a patient in a high oxygen environment massivelydecreases bacteria's ability to function, potentially helps to kill that infection,helps to block the toxicity of that infection and helps to break down the biofilmsaround that infection. So, hyperbaric becomes an amazing tool in the capacityof immune system balancing and/or ability to help fight infection.”
More Information
As a general guidance, Sonners recommends doing hyperbaric for about two hours a week on a regular basis. That's his personal routine. In addition to that, three times a year he does a 30- to 40-hour protocol over the course of six to eight weeks. He explains why:
“We know that in general ... three or four sessions is not going to ever cut it.The main effect of hyperbaric is really achieved through the cumulative effectand the increasing and decreasing — the wave of hyper-oxygenation back tonormal oxygen levels — creating that hyperoxia-hypoxia type paradox ...When you do a protocol similar to like what I would do for a patient, let's sayfour to six hours a week for eight weeks, the frequency of those ... the space inbetween them, really shrinks and you get far more signaling to occur ...If all we cared about was the physical dose, we would stay at 100% oxygen aslong as we possibly could, at the highest pressure we could tolerate to get themost oxygen absorption. I don't think that that's where the majority of benefitexists.Every time your pressure changes or your percentage of oxygen changes, you'restimulating HIF-1 alpha, the reactive oxygen species load, sirtuins, you'resignaling a hormetic effect. I picture them as switches. You're fiipping thatswitch on, off, on, off, on, off. I think it's the amount of times that you stimulatethat switch that will create the benefits we're looking for, more than the physicaldose of oxygen over time.”
To learn more about HBOT in general, be sure to pick up Sonners' book, “ Oxygen Under Pressure: Using Hyperbaric Oxygen to Restore Health, Reduce Infiammation, Reverse Aging and Revolutionize Health Care .” In the interview, we also discuss how you can incorporate HBOT in your fitness routine, along with fasting, to augment and upregulate cellular performance, recovery and regeneration. So, if that's of interest to you, be sure to listen to the interview in its entirety, or read through the transcript.
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