Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms – A Randomized Clinical Trial

After years of research, Dr. Lipov’s treatment has been proven – by a now-published clinical trial – to make “a significant difference” for veterans with PTSD.

From the article: 
Key Points

Question  How does stellate ganglion block compare with sham treatment in reducing the severity of posttraumatic stress disorder symptoms over 8 weeks?

Findings  In this sham-controlled randomized clinical trial, 2 stellate ganglion block treatments 2 weeks apart were effective in reducing Clinician-Administered PTSD Scale for DSM-5 total symptom severity scores over 8 weeks. The adjusted mean symptom change was −12.6 points for the group receiving stellate ganglion blocks, compared with −6.1 points for those receiving sham treatment, a significant difference.

Meaning  Stellate ganglion block treatment warrants further study as a posttraumatic stress disorder treatment adjunct.

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Click here to read in the Journal of the American Medical Association

Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms – A Randomized Clinical Trial

After years of research, Dr. Lipov’s treatment has been proven – by a now-published clinical trial – to make “a significant difference” for veterans with PTSD.

From the article: 
Key Points

Question  How does stellate ganglion block compare with sham treatment in reducing the severity of posttraumatic stress disorder symptoms over 8 weeks?

Findings  In this sham-controlled randomized clinical trial, 2 stellate ganglion block treatments 2 weeks apart were effective in reducing Clinician-Administered PTSD Scale for DSM-5 total symptom severity scores over 8 weeks. The adjusted mean symptom change was −12.6 points for the group receiving stellate ganglion blocks, compared with −6.1 points for those receiving sham treatment, a significant difference.

Meaning  Stellate ganglion block treatment warrants further study as a posttraumatic stress disorder treatment adjunct.

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Click here to read in the Journal of the American Medical Association

Possible Reversal of PTSD-Related DNA Methylation by Sympathetic Blockade (pdf enclosed)

Publication: Journal of Molecular Neuroscience
Date: March 2017
Author: Eugene G. Lipov & Kenneth Candido & Elspeth C. Ritchie

Abstract:

Studies have shown that brain-derived neurotrophic factor (BDNF) level increase is associated with post-traumatic stress disorder (PTSD) risk. BDNF may be a missing-link^ that mediates the interaction between genetics, environment, and the sympathetic system. Trauma has been shown to induce DNA methylation that in turn can increase
BDNF concentration due to increased gene expression. Therapies that focus on the reduction of beta-NGF (BNGF) levels may impact PTSD symptoms. The focus of this paper is to discuss possible effect of stellate ganglion block (SGB) on epigenetic changes noted with PTSD mediated by BDNF and NGF. Stellate ganglion block has recently shown significant therapeutic efficacy for treatment of PTSD symptoms. Previously reported theoretical mechanisms of SGB impact on PTSD have focused on likely reduction of NGF, leading to eventual loss of extraneous sympathetic nerve growth, eventually leading to reduction of secondary norepinephrine level, which in turn is hypothesized to reduce PTSD symptoms. We used PUBMED to obtain available data following a search for the following: DNA, neurotrophic factors, post-traumatic stress disorder, and demethylation following local anesthetic application. A number of articles meeting criteria were found and reviewed. Based on the evidence summarized, trauma can lead to DNA methylation, as well as BNGF/NGF level increase, which in turn starts a cascade of sympathetic sprouting, leading to increased brain norepinephrine, and finally symptomatic PTSD. Cascade reversal may occur in part by demethylation of DNA caused by application of local anesthetic to the stellate ganglion.

SA-Lipov-possible-reversal-of-ptsd-related-dna

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V.A. Evidence Brief: Effectiveness of Stellate Ganglion Block for Treatment of Posttraumatic Stress Disorder (PTSD) (pdf enclosed)

Publication: Department of Veterans Affairs, Veterans Health Administration,Quality Enhancement Research Initiative, Health Services Research & Development Service
Washington, DC 20420
Date: February 2017
Author: Evidence-based Synthesis Program (ESP), Coordinating Center, Portland VA Health Care System, Portland, OR, Mark Helfand, MD, MPH, MS, Director

Summary:
Emergence of an intervention’s first randomized trial is always a highly anticipated event. For SGB, however, findings from its first randomized trial for PTSD proved to be disappointing. In uncontrolled, unblinded, retrospective case series, SGB for PTSD had high rates of rapid clinical improvement in PTSD symptoms (70% to 75%). In the RCT, the range of mean percent PTSD improvement after one round of SGB was 5.4% to 14.7%, and was 12.1% to 21.2% after the second round, which was no better than an injection of saline. The RCT was too small to estimate complication rates and did not report the number of patients in each group, if any, who responded to treatment. Instead it reported group averages. What do we make of this? It is not surprising that SGB’s benefits were less impressive in the RCT than in the case series, as empirical evaluation has shown that, on average, benefits are generally larger in observational studies.66 However, what was surprising is that by using a somewhat lower than usual dose of ropivacaine (5 cc versus 7 cc) and a population that may have been motivated to resist treatment, design features may have limited the RCT’s chances of generating meaningful data on efficacy.71 Substantial uncertainty remains about the potential harms of SGB as well, as the RCT and previous case series in PTSD, as well as RCTs for CRPS, 68 were inadequately powered to support or refute findings from the 1992 German questionnaire survey of 45,000 SGBs. We agree with the conclusions of previous reviews that further research is needed to more precisely determine the balance of benefits and harms of SGB for PTSD.39,52,72.

SA-Lipov-VA-evidence-brief-stellate-ganglion-block

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With War-Related Post Traumatic Stress Disorder Being Resistant to Pharmaceuticals is it Time to Give Stellate Ganglion Block (SGB) a Shot? (pdf enclosed)

Publication: Journal of Trauma and Treatment
Date: August 2015
Author: Eugene Lipov*
Advanced Pain Centers, Hoffman Estates, Illinois, USA
Abstract:

A large number of war veterans have PTSD in US military punctuated by a very high suicide rate of 22 per veterans per day. Current VA gold standard” treatments protocols will effectively reach no more than 20% of all veterans needing PTSD treatment. A recent study reported results multi- center study on off-label use of second-generation (atypical) antipsychotics has gained wide popularity Risperidone and demonstrated no benefit over placebo for military-related PTSD. This leaves practitioners with few weapons in their pharmacotherapeutic arsenal. The risks of SGA’s are significant, such as sudden heart failure and increase the risk of suicidal attempts, pharmaceutical ap-
proach may be moving away from this conventional path. New techniques include modulation of the sympathetic nervous system (SNS) which is a part of the autonomic nervous system. It turns out that a possible treatment of physiologic hyper arousal is available by utilizing minimally invasive modulation of sympathetic nervous system. It seems possible to have similar results by using a common anesthetic procedure called Stellate ganglion Block ( SGB) which is much less invasive. Early results of this new approach are very promising, with a success rate of 70 to 75% a very high compliance, acceptance and minimal risk. Considering severity of PTSD and the lack of effective therapeutic interventions available it is time to dispense with established scientific /medical opinions look at the available data and apply SGB to the population most at risk of PTSD related complications.

SA-Lipov-With_War-Related_Post_Traumatic_Stress_Disorder_Be

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Please help veterans/service members receive this treatment by donating to Dr. Lipov’s Foundation: http://globalptsifoundation.org/donate

With War-Related Post Traumatic Stress Disorder Being Resistant to Pharmaceuticals is it Time to Give Stellate Ganglion Block (SGB) a Shot? (pdf enclosed)

Publication: Journal of Trauma and Treatment
Date: August 2015
Author: Eugene Lipov*
Advanced Pain Centers, Hoffman Estates, Illinois, USA
Abstract:

A large number of war veterans have PTSD in US military punctuated by a very high suicide rate of 22 per veterans per day. Current VA gold standard” treatments protocols will effectively reach no more than 20% of all veterans needing PTSD treatment. A recent study reported results multi- center study on off-label use of second-generation (atypical) antipsychotics has gained wide popularity Risperidone and demonstrated no benefit over placebo for military-related PTSD. This leaves practitioners with few weapons in their pharmacotherapeutic arsenal. The risks of SGA’s are significant, such as sudden heart failure and increase the risk of suicidal attempts, pharmaceutical ap-
proach may be moving away from this conventional path. New techniques include modulation of the sympathetic nervous system (SNS) which is a part of the autonomic nervous system. It turns out that a possible treatment of physiologic hyper arousal is available by utilizing minimally invasive modulation of sympathetic nervous system. It seems possible to have similar results by using a common anesthetic procedure called Stellate ganglion Block ( SGB) which is much less invasive. Early results of this new approach are very promising, with a success rate of 70 to 75% a very high compliance, acceptance and minimal risk. Considering severity of PTSD and the lack of effective therapeutic interventions available it is time to dispense with established scientific /medical opinions look at the available data and apply SGB to the population most at risk of PTSD related complications.

SA-Lipov-With_War-Related_Post_Traumatic_Stress_Disorder_Be

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Please help veterans/service members receive this treatment by donating to Dr. Lipov’s Foundation: http://globalptsifoundation.org/donate

Correspondence: It Is Time to Address the Crisis in the Pharmacotherapy of Posttraumatic Stress Disorder: A Consensus Statement of the PTSD Psychopharmacology Working Group (pdf enclosed)

Publication: Biological Psychiatry
Date: 2017

Authors: John H. Krystal
Lori L. Davis
Thomas C. Neylan
Murray A. Raskind
Paula P. Schnurr
Murray B. Stein
Jennifer Vessicchio
Brian Shiner
Theresa D. Gleason
Grant D. Huang

There is an urgent need to address a critical lack of advancement in the psychopharmacologic treatment of posttraumatic stress disorder (PTSD). The clinical, social, and financial burden of ineffectively treated PTSD is enormous (1–6)…

SA-biological-Psychiatry-Krystal-crisis

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Sympathetic system modulation to treat post-traumatic stress disorder (PTSD): A review of clinical evidence and neurobiology (pdf enclosed)

Publication: Elsevier – Journal of Affective Disorders
Date: July 2012

Eugene Lipov, Briana Kelzenberg
Advanced Pain Centers, 2660 W. Higgins Road, Suite 101, Hoffman Estates, IL 60169, United States

Abstract: A review of clinical evidence and neurobiology on the effects of modulation of sympathetic system modulation to treat post-traumatic stress disorder (PTSD) is being presented . The review provides an overview of currently available treatments followed by efficacy of orally effective sympathetic blocking agents. The main focus of the review is the application of stellate ganglion blocks (SGBs) or a local anesthetic blockade of the sympathetic ganglion in the neck.

SA J_Affect_Disord_Lipov

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A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD) (pdf enclosed)

Publication: Elsevier
Date: January 2009

Eugene G. Lipov a,*, Jaydeep R. Joshi a, Sarah Sanders a, Konstantin V. Slavin b

a Advanced Pain Centers S.C., 2260 W. Higgins Rd., Ste. 101, Hoffman Estates, IL 60169, United States
b Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States

Summary:
The mechanism of action of the stellate ganglion block (SGB) is still uncertain; however it has been used successfully in treatment of chronic regional pain syndrome (CRPS) for many years. Our new insights in to the mechanism of action of the stellate ganglion block were first reported in 2007 in our publication detailing the control of hot flashes with the use of stellate ganglion blockade. We have demonstrated very significant results in the treatment of hot flashes and our most recent application of this block has been
for the treatment of posttraumatic stress disorder (PTSD).
Stellate ganglion has been demonstrated to have second and third order neurons connections with the central nervous system nuclei that modulate body temperature, neuropathic pain, the manifestations of PTSD, and many other areas.
We believe that the commonality between the CRPS, HF and PTSD is the trigger of increased nerve growth factor (NGF) leading to the increase in brain norepinephrine (NR), which in turn is affected by the SGB leading to a prolonged reduction of NGF and eventually a decrease in NR. This, in turn, leads to a reduction or elimination of many of the symptoms of CRPS, Hot flashes, and PTSD.

SA unified_theory-published

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Use of Stellate Ganglion Block for Refractory Post-Traumatic Stress Disorder: A Review of Published Cases (pdf enclosed)

Publication: Journal of Anesthesia & Clinical Research
Date: January 2014

Abstract
Introduction: The lifetime prevalence of post-traumatic stress disorder (PTSD) is estimated to be 7.3% in the U.S. population, 10-20% among active duty service members and 35-40% among veterans. Overall success rates of evidence-based therapies for PTSD are low, leading clinicians to explore new therapeutic options. This study
evaluated all published articles on the use of stellate ganglion block (SGB) as an adjunctive therapy for treatmentrefractory PTSD.

Methods: EMBASE, PubMed, PsychINFO and Cochrane databases were searched using keyword combinations including stellate ganglion block, SGB, post-traumatic stress disorder, and PTSD. Articles were restricted to English language with no date delimiter. Twelve publications were identified, seven of which were eliminated due to lack
of case data, duplicate patient sample, or descriptive reports with no standardized PTSD symptom assessment. Twenty-four cases from five articles were examined further by two independent evaluators who extracted data on sociodemographic and clinical characteristics including PTSD symptoms, comorbidities, and treatment history. Interrater reliability showed complete agreement (κ=1.0).

Results: Cases were predominantly male (n=21, 88%) and active duty military (n=14, 58%) or veterans (n=8, 33%) with combat-related PTSD. The average age was 40.5 years (±10.0 SD). All cases had received >1 year of psychotherapy and pharmacotherapy before SGB. Seventeen cases (71%) received one SGB, seven (29%) received multiple SGBs. Clinically meaningful improvements were observed in 75% (n=18) of cases after SGB, with significant differences in mean PTSD scores pre- (69.5 ± 26.6) and post-SGB (34.2 ± 32.5) across cases (p<0.001). The effect size was relatively large (d=1.2). On average, PTSD improved by 50.4% (± 30.9 SD; range: 6.3-98.4) for cases with one SGB and 69.0% (± 28.0 SD; range: 9.2-93.5) for cases with multiple SGBs.

Conclusions: Most patients with treatment-refractory PTSD experienced rapid improvement after SGB. Robust clinical trials are needed to determine SGB’s treatment efficacy for PTSD.

PDF: Use_of_Stellate_Ganglion_Block_for_Refractory_Post (1)

Maryam Navaie1*, Morgan S. Keefe2, Anita H. Hickey3, Robert N. McLay4, Elspeth Cameron Ritchie5 and Salahadin Abdi6
1 Advance Health Solutions, LLC, Washington, USA
2 Advance Health Solutions, LLC, San Diego, USA
3 Department of Anesthesiology, United States Naval Hospital Okinawa, Japan
4 Department of Mental Health, Naval Medical Center San Diego, USA 5Department of Mental Health, District of Columbia, USA
6 Department of Pain Medicine, University of Texas MD Anderson Cancer Center, USA

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