National Center for Healthcare Advancement and Partnerships
HAP Healthcare Advancement Initiative News
Stellate ganglion block works for PTSD, can be an additional option for Vets, say three VA doctors
The VHA National Center for Healthcare Advancement and Partnerships (HAP, formerly the Office of Community Engagement [OCE] and Center for Compassionate Care Innovation [CCI]) continues to collaborate with VA providers to explore innovations in health care such as stellate ganglion block (SGB) for Veterans diagnosed with posttraumatic stress disorder (PTSD). SGB involves the application of a local anesthetic near a nerve bundle in the neck called the stellate ganglion. Three VA doctors recently spoke about expanding the use of SGB, misperceptions about the treatment, and how VHA providers might consider it as a potential option for Veterans with PTSD.
Doctors Christopher Reist, Michael Alkire, and Michael Hollifield started a clinic providing SGB for Veterans with PTSD at VA Long Beach Healthcare system, where doctors have performed the procedure more than 340 times with 140 Veterans since 2017. SGB is not considered an established first-line treatment for PTSD at this time because the evidence is not conclusive. Currently, individuals with PTSD should be strongly encouraged to try established and recommended treatments such as trauma-focused psychotherapy and medications.
For Veterans who don't benefit from these traditional treatments, alternative interventions such as SGB might be considered. It is not known exactly how the treatment works, but, according to the Long Beach doctors, SGB likely affects the parts of the brain that manage anxiety and appears to calm the “fight or flight” feeling many Veterans diagnosed with PTSD experience
While SGB has been used for the treatment of chronic pain conditions, and some VA facilities may offer it in that context, mental health providers may not be familiar with the procedure. Recent developments within VA could be changing that, Dr. Hollifield explained.
“Long Beach VA and its leadership decided that, based on extant data and our clinical experience, SGB is likely a useful procedure, so we have developed an SGB for PTSD Innovation Program (SPIP),” he said. All three doctors will be involved with SPIP. “We’ve designed the SPIP to be a comprehensive and Veteran-centric program where Veterans who receive SGB are offered follow-up treatment with trauma-focused psychotherapy, biofeedback, acupuncture, or a combination.” The SPIP has a Quality Assessment component and education component to help other VA’s learn from our experience.”
One of the obstacles to widely implementing SGB across VA is that the long-term effects of SGB are unknown, and SGB has not been fully researched in Veterans with PTSD. There is some uncertainty around what it does, how it works, and how well it can work in combination with other therapies.
“SGB sort of goes against the dogma of what PTSD is, that it is fundamentally a psychological problem,” explained Dr. Reist. “This treatment doesn’t involve a psychological treatment, so therefore it’s viewed with some skepticism.”
Dr. Hollifield agreed. “PTSD is not fundamentally a psychological disorder, it’s an environmentally caused disorder of brain-body disruption that affects essentially all systems in the body, resulting in more inflammation, more risk of heart disease, more risk of diabetes and arthritis and severely affects psycho-social functioning.”
The doctors explained that treatments such as SGB for PTSD do have a significant history. Successful use of SGB specifically for PTSD dates back to 2008, and another case in 1990 showed that SGB reduced the patient’s co-occurring PTSD symptoms.
Decisions to offer SGB as an experimental procedure for PTSD are made by the local VA facility leadership and the procedure is completed by a trained specialist (such as an anesthesiologist or other similarly trained medical provider). If Veterans ask their VA health care providers for more information about SGB, providers might have to respond that the treatment is not done at their facility, or that it is unproven. For that to change, there needs to be even more data about SGB.
“It probably does not yet rise to the level of proof as some other treatments. But in order for data to be generated as proof, there must be an acceptance of and openness to study it,” said Dr. Hollifield. “Before we had any good data about any treatment such as psychotherapy, or before we did our first study about acupuncture for PTSD, people would question how they would even work.”
SGB may reduce symptoms of PTSD for at least a few weeks. A second injection may provide additional benefit in some individuals. It is possible that SGB may be helpful when used in combination with evidence-based PTSD treatment, such as prolonged exposure therapy, cognitive processing therapy, or eye movement desensitization and reprocessing (EMDR) therapy. Dr. Reist said SGB may be an option for Veterans psychotherapy or medications.
“It remains an option for people who may not have other treatments,” he said.
For more information on SGB for PTSD, read the VA Evidence Synthesis Program brief here: https://www.hsrd.research.va.gov/publications/esp/ganglionblock.cfm
View the VA HSR&D cyber seminar on the Department of Defense trial of SGB for PTSD here: https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=3749
For more information on HAP, visit: https://www.va.gov/HEALTHPARTNERSHIPS/haproposals.asp.
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Article originally posted March 29, 2021. Updated July 20, 2021.
