Hyperbaric Oxygen Therapy After Neurological Injury: A Case That Raised a Question, and What the Research Actually Shows

A Clinical Observation That Raised the Question

A few months ago, while following a patient with both a traumatic brain injury and a spinal cord injury, I noticed something during a routine visit: his fine motor coordination had visibly improved. His hands, which were usually contracted, were opening and closing on command, and he was moving his extremities more than I'd previously observed. The change coincided with a period of increased oxygen intake following a recent surgery, his airway had just been cleared post-op.

It was a small, unofficial observation, but it was hard not to notice. I raised it with the treating physiatrist and asked whether hyperbaric oxygen therapy (HBOT) might be worth exploring to build on what looked like a positive response to improved oxygenation.

The answer I got back was an important reality check: HBOT isn't indicated for TBI, and it can actually increase seizure risk. It's used for wound and skin healing, but not for the brain injury itself.

A Dual Diagnosis Complicates the Picture

Here's the part that makes this case genuinely interesting rather than a simple "no": this patient carries both diagnoses. The physiatrist's caution was specific to the TBI side of the picture, the seizure risk and lack of indication apply to brain injury. But the movement I observed in his extremities is exactly the kind of outcome the spinal cord injury literature has actually studied, with more encouraging (if still limited) results: reduced spasticity, improved motor scores, and reduced contractures show up as themes across several SCI trials, tied to oxygenation's role in calming the inflammatory cascade that follows a cord injury.

So which injury explains what I saw? Honestly, it's not possible to say from a single bedside observation. A few things are worth holding onto:

• What I observed followed increased supplemental oxygen after airway clearance, not an actual hyperbaric oxygen chamber session. Regular oxygen at normal atmospheric pressure and hyperbaric oxygen at increased atmospheric pressure are related but different interventions, the mechanism research on HBOT specifically involves the pressurized, plasma-dissolved-oxygen effect, which a nasal cannula or open airway doesn't replicate. So this observation is better described as "oxygenation seemed to matter" rather than direct evidence that HBOT itself would help.

• A dual TBI/SCI patient sits at the intersection of two different evidence bases with two different risk profiles. The SCI research is cautiously encouraging; the TBI research carries a specific safety flag. Whether HBOT would be appropriate for this patient isn't answered by either literature in isolation, it requires weighing the SCI potential against the TBI risk for that specific patient, which is exactly the kind of judgment call that belongs to the treating physiatrist, informed by imaging, seizure history, and the full clinical picture.

• The physiatrist's response addressed the TBI question I actually asked; it wasn't a ruling on the SCI question, since I didn't ask that at the time. That's a genuinely open conversation worth having with the care team, not something to assume an answer to either way.

  
  

What HBOT Is Supposed to Do

HBOT involves breathing 100% oxygen in a pressurized chamber, which dramatically increases the amount of oxygen dissolved directly in the blood plasma, well beyond what's possible breathing pure oxygen at normal atmospheric pressure. In the context of SCI, the theory centers on the "secondary injury" phase: the cascade of inflammation, ischemia, swelling, and cell death that continues to damage the spinal cord in the hours and days after the initial trauma.

The proposed mechanisms, consistent across both animal and human studies, include:

• Increased oxygenation to the injured tissue, supporting neural cell survival

• Reduced inflammation, including suppression of pro-inflammatory (M1) macrophage activity

• Angiogenesis — stimulating new blood vessel growth to improve blood flow to the injury site

• Antioxidant effects, boosting the body's own free-radical-fighting enzymes

  
  

What the SCI Studies Found

The research base is still fairly small, but a few studies stand out:

• A randomized trial of 79 acute SCI patients found HBOT significantly reduced inflammatory markers (HMGB1 and NF-κB), correlating with better neurological recovery.

• A study of 78 post-surgical incomplete cervical SCI patients found the HBOT group had significantly better ASIA motor scores than the non-HBOT group.

• A study of 60 patients with incomplete SCI found eight weeks of HBOT alongside routine rehab significantly reduced depression scores: suggesting benefits that go beyond physical recovery.

• An earlier trial in acute traumatic cervical SCI found HBOT patients recovered motor function faster, but final motor scores ended up similar to patients who received conventional therapy alone.

• A 2021 systematic review and meta-analysis pooling multiple randomized trials found HBOT patients showed greater improvement in motor function, sensory function, and psychological measures within the first 30 days.

  
  

What All the SCI Studies Have in Common

A few threads run through nearly every paper on this topic, regardless of whether it was a rat study or a clinical trial:

1. Same mechanism, every time. All of them point back to the same secondary-injury framework: inflammation, ischemia, oxidative stress: as the target.

2. Timing matters. Studies that looked at this consistently found earlier initiation after injury produced better outcomes.

3. A positive, if modest, signal. No study found HBOT made outcomes worse in SCI. Most found some measurable benefit, even if effect sizes were small.

4. Small, inconsistent studies. Sample sizes typically ranged from 60–90 patients, with wide variation in dosing, pressure, and timing protocols from one study to the next.

5. Universal call for more research. Nearly every paper's conclusion explicitly calls for larger, standardized, multicenter trials before firmer conclusions can be drawn.

   
   

Why Isn't HBOT FDA-Cleared for Spinal Cord Injury?

HBOT chambers are regulated by the FDA as Class II medical devices, but the specific conditions they're cleared to treat come from a list of 14 indications maintained by the Undersea and Hyperbaric Medical Society, things like: carbon monoxide poisoning, decompression sickness, diabetic wounds, and radiation injury. Spinal cord injury simply isn't on that list, which means any use for SCI is considered off-label.

It's not that regulators reviewed the evidence and rejected it: it's that the evidence hasn't yet reached the scale and consistency typically required to add a new indication. That requires large, well-powered, multicenter trials with a standardized protocol (timing, pressure, duration, number of sessions) and clear criteria for which patients are likely to benefit. None of that exists yet for SCI. Complicating it further for patients like the one described here: even if the SCI evidence continues to mature, a coexisting TBI with its own seizure-risk profile would still need to be part of that conversation. Until the evidence and the guidelines catch up, insurance generally won't cover HBOT for SCI, and patients seeking it typically pay out of pocket at independent clinics.

The Takeaway

The direction of the SCI evidence is encouraging, reduced inflammation, better standardized recovery scores, and even mood benefits show up across multiple independent studies.

If a patient or family member asks about HBOT, the honest answer is: the science is genuinely promising for some conditions, carries real risks for others, the trials behind it are still small and inconsistent, and any decision to pursue it should be made in conversation with the full care team, weighing every diagnosis a patient carries, not just the one the question was originally about.

Sources:

• Alqasmi, H., et al. (2026). The role of hyperbaric oxygen therapy for treating spinal cord injury: Mechanisms, considerations, and research outcomes. eNeurologicalSci, 43, 100608.

• Huang, L., et al. (2021). Effects of hyperbaric oxygen therapy on patients with spinal cord injury: A systematic review and meta-analysis of Randomized Controlled Trials. Journal of Back and Musculoskeletal Rehabilitation, 34, 905–913.

• Sun, L., et al. (2019). Effect of hyperbaric oxygen therapy on HMGB1/NF-κB expression and prognosis of acute spinal cord injury: a randomized clinical trial. Neuroscience Letters, 692, 47–52.

• Zhang, Z., et al. (2022). Effects of hyperbaric oxygen therapy on postoperative recovery after incomplete cervical spinal cord injury. Spinal Cord, 60(2), 129–134.

• Feng, J.-J., & Li, Y.-H. (2017). Effects of hyperbaric oxygen therapy on depression and anxiety in the patients with incomplete spinal cord injury. Medicine, 96(29).

• Patel, N. P., & Huang, J. H. (2017). Hyperbaric oxygen therapy of spinal cord injury. Medical Gas Research, 7(2), 133–143.

Note: The clinical case described above has been fully de-identified — no patient name, case number, employer, or provider identity is included — and is shared solely to illustrate the clinical reasoning process.