Combining Stellate Ganglion Block with Prolonged Exposure for PTSD: A Randomized Clinical Trial

Mar 06, 2024

Prolonged Exposure (PE) therapy is the most widely researched behavioral therapy for posttraumatic stress disorder (PTSD) and has shown to be an effective treatment. However, recovery rates have not been as high among military personnel and veterans as with civilians. Massed PE, delivered during a shortened period of 10 daily sessions over two weeks, has shown to be more effective and better received among this population than standard treatment, with fewer patients dropping out.

PE therapy can be challenging because, to help patients process and gain control over their traumatic memories, it requires them to retell the story of their traumatic experience, a part of the therapy called imaginal exposure. PE also involves gradual exposure to real-world situations that are safe but that trigger memories or feelings associated with the trauma. The related, temporary increase in physiological stress can make the therapy difficult to tolerate and potentially decrease efficacy.

Other research has demonstrated improvements in PTSD symptoms from a stellate ganglion block (SGB), an injection of a local anesthetic into a group of nerves located on the side of the throat, which are part of the sympathetic nervous system. But the results were temporary, requiring subsequent SGB injections to reduce the symptoms again.

Pilot study shows potential for improved outcomes

In a recent pilot study, STRONG STAR investigators led by Alan L. Peterson, PhD (Lt Col, USAF Ret.), of The University of Texas Health Science Center at San Antonio, combined massed PE with SGB. This combination resulted in the greatest reduction in PTSD symptoms seen in any of the 25 clinical trials conducted by STRONG STAR and the Consortium to Alleviate PTSD to date. And the symptom reductions lasted over time.

The investigators believe they achieved these results because the SGB reduced physiological arousal, allowing patients to engage more productively during their therapy sessions. Participants reported lower physiological distress but were still able to access their emotions during the imaginal exposure and post-exposure processing.

Further testing with a randomized clinical trial

Dr. Peterson’s team will now test this combined treatment approach with 140 patients with PTSD diagnosis recruited from military treatment facilities at Fort Cavazos (formerly Fort Hood) and at Joint Base San Antonio-Fort Sam Houston, both in Texas.

All patients will receive massed PE therapy, but only half will receive a real SGB injection. The other half will receive a placebo injection for purposes of the study. However, following their study assessment one month posttreatment, those who received a placebo will be offered an SGB.

Expected outcomes and ultimate benefits

The investigators hypothesize that the patients receiving the SGB with massed PE will show greater reductions in PTSD symptoms than those receiving the placebo. They also believe that those receiving the SGB will experience less physiological arousal during imaginal exposure, compared to the placebo group, and that those decreases will be associated with greater reductions in PTSD symptoms.

They believe that if the study is successful, it could not only improve mental health outcomes for individuals, but also potentially improve long-term retention of active duty military personnel, decrease suicide rates among service members, and decrease medical costs associated with treating PTSD and comorbid conditions.

Project MARCH: Multisite Advancement of Research on Chronic Posttraumatic Headache

Jul 24, 2023

Nearly 3 million U.S. service members have deployed since 9/11, with up to 690,000 estimated to have suffered a traumatic brain injury (TBI). Posttraumatic headache (PTH), or headache onset or worsening after a head or neck injury, is the most common and disabling symptom from TBI. Other co-occurring conditions, such as posttraumatic stress disorder (PTSD), also can compound or even cause headaches. A national study showed chronic PTH (lasting more than 3 months) among 60%-65% of veterans with service-related TBI. Other studies have shown high unemployment rates and decreased activity levels in this population even 10 years after injury.

Non-medication treatments are needed
However, military PTH is poorly understood, with little guidance from research on how to manage it effectively. Due to its similarity to migraines, PTH is typically treated with the same types of medications. However, medication does not cure PTH, and overuse can worsen it, while side effects cause many to avoid or discontinue their use. And since medications do not address contributing factors like PTSD, there is great need for non-medication treatments for co-occurring psychological problems.

A promising non-medication intervention
In the first large, randomized clinical trial for military-related headache, a group of investigators successfully treated manualized, multi-component, cognitive-behavioral therapy for migraine headache adapted specifically for military PTH. The research team led by Donald McGeary, PhD, of the University of Texas Health Science Center at San Antonio, used a treatment called Combined Cognitive-Behavioral Therapy for PTH. It led to significant, lasting improvement in PTH and related disability in veterans who had PTH and PTSD symptoms and was as effective as a top PTSD therapy in reducing PTSD symptoms. By comparison, veterans receiving treatment as usual at a U.S. Department of Veterans Affairs (VA) polytrauma center showed no significant improvement in disability.

Building on success of previous trial
Dr. McGeary’s group has designed a STRONG STAR-affiliated study to build on that success. The group will enroll 525 participants from clinics at seven VA and U.S. Department of Defense sites nationwide. Military personnel and veterans who have chronic PTH with or without PTSD will be assigned randomly to one of three treatment arms: Combined Cognitive-Behavioral Therapy (CCBT), Telemedicine-Based Combined Cognitive-Behavioral Therapy (TCBT), or treatment as usual. That will allow investigators to compare CCBT and TCBT to treatment as usual among patients with diverse demographics, trauma and headache histories, and comorbidities and when delivered in different military and VA settings. It also will provide evidence about the therapy’s efficacy when delivered via telehealth, compared to in-person in a clinic. The research group will include Co-Principal Investigator Blessen Eapen, MD, chief of Physical Medicine & Rehabilitation at the Greater Los Angeles Veterans Health Care System, who has extensive experience in military trauma research.

Potential relief for thousands
If successful, this study will provide a needed evidence-based, non-medication treatment for reducing PTH and PTSD symptoms and disability that can be widely disseminated in military and VA facilities to a diversity of patients. Validation of the treatment via telehealth would further expand access at smaller or more remote locations. CCBT and TCBT potentially could improve the lives of hundreds of thousands of service members and veterans, boost military readiness, and reduce military and VA disability costs. With the high prevalence of PTH in civilians, the treatment also could benefit the general public.