Alternative Therapies, Inherent Risks and Effectiveness #1: Hyperbaric Oxygen

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“The Rationale of Hyperbaric Chambers in Treating Autistic Syndrome and Cerebral Palsy Patients”

by Fernando Miranda, M.D., F.A.A.N.

 

As the diagnosis of Autistic Syndrome (ASD) grows, there are many therapies utilized in this field that had not been scientifically assessed and may potentially have negative effects on the patient.

One of these is hyperbaric oxygen treatment.

Through my years of dealing with patients with the diagnosis of ASD and Cerebral Palsy, I have found families investing in this expensive treatment and occasionally buying the equipment so that they can perform the treatment at home with an increased frequency.

It is clear from the medical literature that hyperbaric oxygen therapy has a significant therapeutic effect in infections of limbs, in which anaerobic bacteria is found. Specifically, in gangrene.

It also has a significant role in the treatment of diving encephalopathies (ie, the famous “bends” -Ed), decompression syndromes, for which hyperbaric oxygen is of incredible value as a therapeutic tool.

However, to my knowledge, there is no peer-reviewed journal in the Neurosciences that has noted the value in any situation for ASD or CP.

The postulate in these cases, as it is also for stroke utilization of hyperbaric oxygen, is that supplying oxygen will revitalize areas of the brain that have been damaged by whatever the initial insult has been, and make them functional again.

In stroke, there is a well-recognized area of brain tissue involvement affected by the so-called “penumbra” in which nerve cells are not dead.  Instead, they are damaged and they become nonfunctional.

Treatment with hyperbaric oxygen has been postulated, and in some cases (personal experience) with the hyperbaric chambers at the University of Maryland, we were able to see how an acute stroke would recover normal function in the side of the brain affected.

However, whenever the patient was withdrawn from the chamber, the deficit would recur. The reason for this, was the original cause of the insult was not solved.

In the case of a patient with ASD, in which the Neuropathology shows a minicolumnar neuropathological deficit, hyperbaric oxygen makes no scientific sense.

In patients with Cerebral Palsy, oxygen may reactivate temporarily areas that had been inactive. I have had the opportunity of seeing patients in which this caused a seizure disorder that was subclinical or not apparent before (ie, caused additional seizures -Ed). I have also seen patients who had a seizure disorder as a consequence of congenital damage to the central nervous system (CP) with a seizure disorder, which became intractable after hyperbaric oxygen treatment (ie, HO made brain damage permanent -Ed).

At best, the therapy does not produce any lasting changes in the brain.

It is also important to realize that many of these patients’ families are trying their best to help their children, and this represents an extraordinary expense for which there is no scientific basis for a potential therapeutic effect.

Fernando Miranda, M.D., F.A.A.N.

- – - -

Editor’s notes: HO systems are known to pose a fire hazard risk. Photo from Corbis shown for representative purposes only.

May 16, 2012 update: See ASAT’s response to UPI article over doctor fired by New Jersey hospital who intended to use HBOT for children with autism.

  • By David Freels, October 14, 2011 @ 5:34 am

    Dr Miranda,

    1. If HBOT cannot permanently improve function in brain-injury, please explain the permanent recovery from near comatose TBI as demonstrated in the before/after HBOT video found at hyperbaria.org.

    2. Please provide reference in peer reviewed medical journals documenting occurrence of seizure activity in cerebral palsy from HBOT.

    3. The mechanism and scientific rationale for HBOT in CP and other hypoxic-ischemic brain-injury was published in Exceptional Parent magazine several years ago: “HYPERBARIC OXYGEN THERAPY IN CEREBRAL PALSY AND PEDIATRIC NEUROLOGY: A SCIENTIFIC PERSPECTIVE,” Paul G Harch, MD, The Exceptional Parent. Boston: Jun 2004.Vol. 34, Iss. 6; pg. 39.

    The original article was published with an offer to “provide references upon request.” I have the fully referenced article and will gladly email you a copy at your request.

    3. The Undersea and Hyperbaric Medical Society (UHMS.org) has collaborated with the United States government via Medicare (see page 3 of the pdf located at HBOTdenied.com) to intentionally and deliberately suppress use of HBOT for certain hypoxic-ischemic brain-injury, notably stroke, multiple sclerosis, parkinson’s, alzheimer’s, tbi, etc while permitting use of HBOT for other certain hypoxic-ischemic brain-injury specifically decompression sickness (DCS), air/gas embolism (AE), and carbon monoxide poisoning (CO).

    The typical treatment protocol for DCS, AE, and CO is remedy can be achieved in 10 treatments or less while other brain-injury (such as stroke, cerebral palsy, and autism etc) require 100′s of treatments. If brain-injury were “approved” for these latter indications, this would also force the UHMS to accept a reduction in the reimbursement rate from a typical $2000/hour to the usual $150/hour now found at freestanding HBOT clinics.

    This was admitted by a former UHMS president and original author of Medicare’s “noncovered” list. See http://www.oxyhealth.com/images/noncovered.pdf

    4. The UHMS/US approval of HBOT for some hypoxic-ischemic brain-injury while denying HBOT for other hypoxic-ischemic brain-injury is a direct violation of the Americans with Disabilities Act (ADA).

    5. Parents of brain-injured children have successfully circumvented these institutional, political, and financial barriers to access HBOT through utilization of the federal mandates governing children’s Medicaid services (EPSDT.us). The information required to access HBOT via Medicaid is freely available to all subscribers to the Yahoo group MedicaidforHBOT found at MedicaidforHBOT.com. All members have free access to dozens of court decisions across the US as well as personal assistance and consultation from me should they decide to pursue legal action against their state Medicaid agency. So far 20-something states have covered HBOT.

    In each case coverage was dependent upon proving HBOT efficacy. You are welcome to subscribe to the group and review the decisions.

    David Freels,
    MedicaidforHBOT.com
    david@davidfreels.com

  • By DrMiranda, October 27, 2011 @ 4:09 pm

    Mr. Freels,

    Thank you for your spirited response to my blog post. Healthy discussion is the best way to illuminate all the elements on both sides of the issue. To that effect allow me to respond to your numbered comments.

    \\\\\\\ Your comment: 1. If HBOT cannot permanently improve function in brain-injury, please explain the permanent recovery from near comatose TBI as demonstrated in the before/after HBOT video found at hyperbaria.org. ///////

    There are a plethora of documented cases where patients in full comatose and near comatose states have awakened to full or near full function without any medical intervention aside from the providing of fluids. Literature dictates that neurologic function may continue to improve even 2 years following TBI with some new studies indicating that improvement via neurorehabilitation may continue even up to 5 years from onset of injury (Brain Injury, 1995, Vol. 9, No. 3: Pages 285-299); typically, immediately following TBI there is a 6–12 month period of rapid recovery of cognitive function, followed by plateauing of recovery over 12–24 months subsequent to the injury. Cases and individuals differ widely, as time progresses from the date of TBI, the varieties of neurorehabilitative treatments used in a standard course of rehabilitation grow; consequently confounding definitive determination of what specific treatment may have contributed to improvement. In the specific case in question the majority of the presented enhanced neurologic function occurs within the 6-12 month optimal improvement window, making the conclusion that all neurologic improvement being due to HBOT difficult, particularly given that patients receiving no HBOT would also display marked improvement in that period simply as a result of natural healing and reduction in edema.

    \\\\\\\ Your comment: 2. Please provide reference in peer reviewed medical journals documenting occurrence of seizure activity in cerebral palsy from HBOT. ///////

    As per your request I am providing reference, in respected, peer-reviewed medical journals documenting the occurrence, and risk of seizure activity in patients receiving HBOT, both with and without CP.

    Nuthall G, Seear M, Lepawsky M, Wensley D, Skippen P, Hukin J. Hyperbaric oxygen therapy for cerebral palsy : two complications of treatment. Pediatrics 2000; 106(6):1-5.

    McDonagh MS, Morgan D, Carson S, Russman BS. Systematic review of hyperbaric oxygen therapy for cerebral palsy: the state of the evidence. Dev Med Child Neurol. 2007 Dec;49(12):942-7.

    Hardy, P., Collet, J.-P., Goldberg, J., Vanasse, M., Lambert, J., Marois, P., Amar, M., Montgomery, D. L., Lecomte, J. M., Johnston, K. M. and Lassonde, M. (2002), Neuropsychological effects of hyperbaric oxygen therapy in cerebral palsy. Developmental Medicine & Child Neurology, 44: 436–446.

    Patrick M. Tibbles, M.D., and John S. Edelsberg, M.D., M.P.H. Hyperbaric-Oxygen Therapy. New England Journal of Medicine 1996; 334:1642-1648 June 20, 1996

    \\\\\\\ Your comment: 3. The mechanism and scientific rationale for HBOT in CP and other hypoxic-ischemic brain-injury was published in Exceptional Parent magazine several years ago: “HYPERBARIC OXYGEN THERAPY IN CEREBRAL PALSY AND PEDIATRIC NEUROLOGY: A SCIENTIFIC PERSPECTIVE,” Paul G Harch, MD, The Exceptional Parent. Boston: Jun 2004.Vol. 34, Iss. 6; pg. 39. The original article was published with an offer to “provide references upon request.” I have the fully referenced article and will gladly email you a copy at your request. ///////

    I have, unfortunately, not had the opportunity to read the periodical (Exceptional Parent) that you refer to as outlining the definitive mechanism and scientific rationale for the use of HBOT in CP. However, I am unsure that “Exceptional Parent” magazine would qualify as a peer-reviewed medical journal such as the type you requested from me to qualify my statements on the risk of seizures in patients with CP receiving HBOT. If you have references quantifying the use of HBOT in patients with CP that come from journals subject to the same level of peer-review and academic rigor as those I have listed above I would be happy to read them.

    \\\\\\\ Your comment: 3. The Undersea and Hyperbaric Medical Society (UHMS.org) has collaborated with the United States government via Medicare (see page 3 of the pdf located at HBOTdenied.com) to intentionally and deliberately suppress use of HBOT for certain hypoxic-ischemic brain-injury [...] If brain-injury were “approved” [...] this would also force the UHMS to accept a reduction in the reimbursement rate from a typical $2000/hour to the usual $150/hour now found at freestanding HBOT clinics. This was admitted by a former UHMS president and original author of Medicare’s “noncovered” list. See oxyhealth.com/images/noncovered.pdf ///////

    As much as I understand your passion on the subject of HBOT, the Undersea and Hyperbaric Medical Society (UHMS) is an AMA recognized board that is considered the expert governing body on the medical applications of HBOT. If they do not find that HBOT has more application beyond certain hypoxic-ischemic brain-injury such as decompression sickness (DCS), air/gas embolism (AE), and carbon monoxide poisoning (CO) then I would assume that such a conclusion is backed by substantial scientific studies. Moreover, there is precedent for similar exclusions in other medical disciplines. It is a simple fact that not all treatments are universally applicable, even within similar pathological states. One could take Aspirin for example; it can be used to thin blood to prevent MI and stroke, but it is not universally applicable to ALL pathologies that require blood thinning. To claim that refusing to approve Aspirin for use in treatment of all pathologies that could benefit from blood thinning is cause for alarm and protest would be disingenuous at best and purposely misleading at worst. I would suggest that as with any new therapy, one should wait for the results of a randomized, controlled trial before recommending HBOT treatment for hypoxic-ischemic brain injuries or other pathologies for which it has not been indicated.

    \\\\\\\ Your comment: 4. The UHMS/US approval of HBOT for some hypoxic-ischemic brain-injury while denying HBOT for other hypoxic-ischemic brain-injury is a direct violation of the Americans with Disabilities Act (ADA). ///////

    As I mentioned above there is no cause for this kind of statement given that treatments are not necessarily universally applicable across or within similar etiologies or pathologies. Patient’s rights are in fact protected by excluding the approval of procedures that have not been proven effective scientifically and with the potential for adverse effects.

    \\\\\\\ Your comment: 5. Parents of brain-injured children have successfully circumvented these institutional, political, and financial barriers to access HBOT through utilization of the federal mandates governing children’s Medicaid services (EPSDT.us). The information required to access HBOT via Medicaid is freely available to all subscribers to the Yahoo group MedicaidforHBOT found at MedicaidforHBOT.com. [...] You are welcome to subscribe to the group and review the decisions. ///////

    Thank you for your kind invitation to your Yahoo group; I will however, have to politely decline. Thank you for your interest and collegial discussion on my blog, perhaps future topics may capture your interest as well.

    Fernando Miranda M.D. F.A.A.N

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