HBOT for Cerebral Palsy
Chapter 3 of the HBOT Manual
This Chapter will gradually grow to be the largest chapter in the Guide to HBOT for Brain Injury.   In addition, many of the chapters of this manual could come under this chapter heading.  Cerebral Palsy is a very large blanket term.  Many diagnosed with CP will also have several of the other problems with specific chapters within this guide so refer to the specialty chapters within those areas.    We will not go into details trying to explain what CP is.  If you are here you probably already know what CP is and you are investigating using Hyperbaric Oxygen Therapy to improve the conditions of the diagnosis.    We will include parent testimonials and studies which may be available along with articles and statements from professionals who are qualified to comment on the subject.  

Click on the area which interests you:

THE CONTROVERSIAL CANADIAN STUDY
CORNELL UNIVERSITY STUDY Dr. Maurine Packard, MD
CLINICALLY OBSERVED REDUCTION OF SPASTlClTY
The Recoverable Brain in Certain Pediatric Patients
HYPERBARIC OXYGEN THERAPY FOR CEREBRAL PALSY CHILDREN
HBO in the Treatment of Asphyxia in New-born Infants Delivered by Caesarean Section
HYPERBARIC OXYGEN THERAPY IN THE PREVENTION OF DELAYED DETERIORATION AND CEREBRAL PALSY FOLLOWING PERIVENTRICULAR DAMAGE IN THE NEWBORN
New Hope for the Neurologic Damaged Child, Cerebral Palsy, Anoxic Ishemic Encephalopathy                         and Traumatic Brain Injury.
Pediatric Cerebral Palsy treated by 1.5 ATA Hyperbaric Oxygen Therapy
"Hyperbaric Oxygen Therapy for children with Cerebral Palsy."
Clinically Observed Reduction of Spasticity in Patients with Neurological Diseases and in Children with Cerebral Palsy from Hyperbaric Oxygen Therapy
The effect of Hyperbaric Oxygen Treatment on Functional Outcomes in Children with Cerebral Palsy: A Single Case Description
TESTIMONIALS FROM PARENTS ON HBOT
CLINICALLY OBSERVED REDUCTION OF SPASTICITY IN PATIENTS WITH NEUROLOGICAL DISEASES AND IN CHILDREN WITH CEREBRAL PALSY FROM HYPERBARIC OXYGEN THERAPY..........MACHADO, J.J.
HBO in the Treatment of Asphyxia in New-born Infants Delivered by Caesarean Section

THE CONTROVERSIAL CANADIAN STUDY
NOTE:   I would strongly suggest reading the following report from Dr. Marois and Dr. Vanasse before reading the study itself.  The study was obviously set up to try to save the Canadian Government money by not offering HBOT to children with Cerebral Palsy.  The study was obviously flawed.  You may here professionals refer to this report without knowing about the many flaws as described below.  I would suggest you print the below report and present it to anyone who is using the Canadian study as a basis for not using Hyperbaric Oxygen Therapy.   There will be a link to the actual study at the bottom of this report.

Analysis of the results of a randomized study of hyperbaric oxygen therapy in the treatment of children with cerebral palsy:

                 Placebo or physiological effect?

Pierre Marois, MD, FRCP(C), Physiatrist and Michel Vanasse, MD, FRCP(C), Neurologist

Introduction

The results of the study of the effects of hyperbaric oxygen therapy (HBO study) in the treatment of children with cerebral palsy have been known for over six months. However, these results are still controversial. The directors of the "Fonds de la recherche en santé du Québec" (FRSQ), the organization responsible for overseeing this study and some researchers, including the principal researcher, Dr. Jean-Paul Collet, are convinced that the improvements observed in both groups of children involved in the study was due solely to a placebo effect. Others, the authors included, believe that the cause or causes of this improvement were not clearly identified by this study and suggest the need to pursue further research of HBO treatment.

We have voiced our opinions on several occasions and are now compelled to document our position in order to enable those interested in this debate to familiarize themselves with our argument, weighing the pros and the cons. We would like to demonstrate that we are not merely presenting an empathetic attitude towards desperate parents faced with the unfortunate condition of their child. Recognizing our limitations in the area of research, we associated ourselves with and collaborated with a team of researchers, clinicians and methodologists possessing the competence required to write the original version of this study, which was left practically unchanged by Dr. Collet. However without prejudice, we feel that our twenty years of experience in paediatric rehabilitation and our involvement in numerous research projects often dealing with experimental treatments gives us the right to voice our opinion. We invite the readers to judge these objective arguments on their own merit.
 
A.HBO Study: The uncontested facts

The consensus of the research group was that the randomized HBO study for children with cerebral palsy demonstrated that:

-Both groups of children that participated in the study showed improvements in mobility as measured by the Gross Motor Function Measure (GMFM), in language skills and in auditory and visual memory.

-The results did not show that the treatment at 1.75 ATA and 100% O² were superior to the so-called "placebo" at 1.3 atmospheres with ambient air. As often pointed out while the research protocol was being developed and in the discussion of the results, the "placebo" was in fact not an inert treatment. We had recommended a true control group that would not have received any treatment.

Furthermore:

-The research group and the scientific advisory committee were of the unanimous opinion that the improvements observed were clinically significant.

-The improvements in the GMFM scores in both groups were observed during the retest three months post-treatment.

-There were no serious side effects in the course of the 2,500 HBO treatments administered during the pilot-study and the double blind study.

-All who evaluated this study acknowledged its scientific merit.

B. The reasons for the improvement

During three long plenary sessions and several other meetings in small groups, the researchers debated the possible explanations for the improvements observed in both groups of children We feel it is appropriate to convey the researchers conclusions with respect to the possible reasons for the observed improvements.

1. A placebo and/or participation effect. According to many researchers the apparent cause of observed improvements is the fact that the individual participated in a study. Without being able to clearly identify the mechanism, studies have shown that the involvement in a research study resulted in improvements in the parameters being evaluated. To explain the observed changes, we have made reference to the placebo effect, the Hawthorne effect, the increased amount of time the parents spent with their children or the increase in the social interaction of the parents and children.

2. The effect of the HBO therapy. As mentioned above, the placebo referred to in this study was not a true placebo. It was a HBO treatment at 1.3 atmospheres of pressure with ambient air. This treatment has an effect on the partial pressure of blood gases and perhaps other physiological effects. It is therefore possible that this treatment could have a beneficial effect at the cerebral level.

Hypotheses not retained by the research team

The team of researchers evaluated the possibility that the improvements were due to the natural evolution in the neurological condition of the subjects or the effect of learning in the tests used. These hypotheses were not retained as the children's development was stable or had shown only slight improvement. The improvement was much greater following the HBO treatment. We also consider that there was no learning effect in the tests used, especially with the GMFM, which was the principal variable.

C. Our Position

Our opinion is based on the following points that we will elaborate:

-The placebo was not in fact inert and it would be more appropriate to claim that these children received a reduced dose of HBO, in other words an exposure to a pressure of 1.3 atmospheres of ambient air.

-Without denying the existence of a placebo effect, or the possibility that the observed improvements are due to the placebo effect, we maintain that there has been no scientific proof that:

-a placebo can significantly improve mobility, language and memory of children with cerebral palsy clinically or statistically. If the results were due to a placebo, then it was as effective on motor performance as the conventional therapy currently considered the most effective treatment (intensive physical therapy) and in a shorter amount of time.

-a placebo can produce long-lasting effects. The improvements were still observed three months post-treatment in the retest of the subjects involved in this study. Without being able to scientifically confirm, the impression of both parents and health care professionals following these children is that the improvements persisted, (one year and more).

-a placebo can result in reproducible improvements from one study to another. The mobility improvements measured by the GMFM in both groups involved in the randomized study were identical to the results of three pilot studies and one case study. We are in agreement with the experts on the scientific advisory committee that there is no irrefutable scientific proof demonstrating any therapeutic benefit of low-pressure hyperbaric therapy. This however does not imply that a beneficial effect does not exist. Some clinical and experimental data allows us to defend this hypothesis.

D. The "placebo" group received a reduced hyperbaric treatment

That the placebo was not inert was not only a concern upon completion of the study, but had been pointed out and discussed during the development of the research protocol. The initial versions of the protocol (versions that were submitted and approved by the ethical committees of Hopital St. Justine, Centre hospitalier regional de Rimouski and Institut en réadaptation en déficience physique de Québec in May 1999) read as follows:

"Since a pressure of 1.3 atmospheres could eventually produce an effect (it is not an inert placebo), we had proposed the introduction of a third group in the study that would not receive any treatment.  The children in the control group would be evaluated, with the awareness that they didn't receive the treatment, initially, one month later and at the end of the study. This group of subjects would allow us to verify the natural evolution of the condition and the effect of repeating the evaluation on the measured performance."

On Dr. Collet's recommendation (eventually approved by the majority of researchers) the inclusion of this third control group was discarded in order to include more subjects in the other two groups thus obtaining more significant statistics.

We were not the only ones to have raised this methodological problem. The results of this study were presented at the Underwater and Hyperbaric Medical Society Conference by Dr. Stéphane Tremblay in June 2000. The report of Dr. Tremblay's presentation states: "many individuals recommend verifying in future studies whether in fact the placebo was inert (28% O2=placebo) as well as the effect of oxygen at partial pressure, seeing as the improvement in both groups was clinically significant." This point was also raised during the presentation of the results of this study at the American Academy of Cerebral Palsy and Developmental Medicine in Toronto, September 2000, given in part by Dr. Michel Vanasse.

A letter addressed to Dr. Collet from Dr. Butcher, the senior editor of the journal The Lancet, accepting the text of the results of our study stated:

"I am very pleased to be able to tell you that The Lancet's editorial team had decided to accept your paper for publication provided that all references to "placebo" are changed to "slightly pressurized room air (or something similar)"."

Evidently these comments do not allow us to conclude that the treatment was responsible for improvements observed in the group that received the attenuated hyperbaric therapy. However, it does indicate that many scientists feel this possibility cannot be excluded and should be the focus of further investigation. It was the conclusion in the resume of the paper written by Dr. Collet, on the results of our study that has been accepted for publication in The Lancet:

"The important improvement observed in both groups for all three dimensions tested deserves further considerations."

E. Comments regarding the "placebo" effect or the effect of participation

1. Placebo effect, effect of participation (inclusion benefit) and "Hawthorne effect"

Without intending to do a complete analysis of the placebo effect, we feel it is important to comment on the subject. During the discussions pertaining to the possible causes of the improvements noted in both groups of subjects, many of the researchers maintained that it was due to a placebo effect, inclusion benefit or "Hawthorne effect" or a combination of the three. The designated committee of experts chosen by the FRSQ concluded that this was the most probable explanation of the reported improvements. Some reproached us for attempting to deny the obvious, that these effects are well known and well documented. If this is in fact the case, it is surprising to report that the paper reporting the results of our study only includes one very general reference to this subject. We do not in any way deny the existence of the placebo effect, however, we have always maintained that there is no scientific proof that such an effect could explain the improvements reported in the children that received either the complete or reduced hyperbaric therapy. The placebo effect is a well-known phenomenon to health care professionals that has rarely been studied. The titles of certain papers cited by the experts of the scientific committee refer to these studies: "The Mysterious Placebo Effect", "The Uncontrollable Placebo Effect".

The effect of participating in a study as possibly being the sole factor resulting in an improvement in the subjects involved was also postulated. It is a fascinating hypothesis and remains just that, a hypothesis. The effect of participating in a study, also referred to as the inclusion benefit, is not well known. Remarks made by Dr. Lantos suggesting this phenomenon remains hypothetical in an editorial in the Journal of Pediatrics 1999, "The "inclusion benefit" in clinical trials":

"As a thought experiment, let us suppose that it is really true that participants in randomized clinical trials do have better outcomes than similar patients with similar diseases treated in the same institution at the same time". In the same editorial he adds: "The phenomenon of inclusion benefit, if real".

The "Hawthorne " effect was also proposed as a possible cause for the reported improvements of the subjects in our study. This effect is defined as: the effect of being conscious of being observed can cause a modification in the behavior of an individual. In a recent study of the "Hawthorne" effect and the sensation of feeling better after anesthesia, De Amici et al. (2000) concluded: "Whereas this study answers the question concerning the importance of the Hawthorne effect in a field where subjective perception is predominant, the impact of this phenomenon on more "objective " parameters remains open. However, the improvements reported in the children treated were based on objective data, not on a sensation of feeling better. These remarks can explain our reluctance to believe that the placebo, the participation or Hawthorne effects be the cause of the reported improvements.

Furthermore:

2. A placebo as effective or even more so than conventional treatment?

We have often mentioned that there are few effective treatments for children with cerebral palsy, and thus the importance of not neglecting a treatment as promising as hyperbaric therapy. In the past few years there have been several papers investigating therapeutic modalities available for children with cerebral palsy, which have concluded that there is no scientific evidence to support the effectiveness of these treatments. (Turnbull 1993, Graves 1995, Majnemer 1998). Dr. Majnemer wrote in her paper: "there is a lack of evidence to support the efficacy of rehabilitation interventions in children with cerebral palsy".

Some open or pilot studies have reported that intensive physical therapy (6 to 8 months, two times a week) result in a functional improvement measured by the GMFM (Gross Motor Function Measure, the evaluation tool used in our pilot and randomized studies). However, for comparable populations, children with spastic diplegia, we observed a 5.3% improvement on the global score of the GMFM in our pilot study (after 20 treatments, after one month) compared to an improvement of 4% reported by Russell et al. ( after 6 months of intensive therapy). Furthermore, in the subjects involved in the randomized study, a generalized improvement was reported, including attention and communication.

We can therefore establish that the hyperbaric therapy resulted in functional improvements more rapidly and more generalized than conventional treatment. If we accept that the improvement observed in the children having received HBO therapy is due to a placebo, must we then conclude the improvements resulting from the 6-8 months of intensive physical therapy were also due to placebo because the results were identical?

3.A reproducible and persisting placebo effect?

Another interesting and, in our opinion, very important element that was highlighted by our research was that the improvements persisted at least three months post treatment. The children were systematically re-evaluated three months later and we were able to document beyond doubt the persistence of the gains observed after 40 hyperbaric treatments (and even a slight improvement which was not statistically significant). In a pilot study Dr. Maurine Packard of Cornell University evaluated 26 children that had received 40 HBO treatments (each lasting one hour at 1.5 ATA). She noted that the improvements in the areas of attention, language and ability to play that were observed immediately after the treatments were still present six months later.

Our clinical experience leads us to believe that the improvements reported persist even in the long term, in other words for at least one year after the treatment. To our knowledge, no scientific proof exists confirming the persistence of a placebo for that period of time.

We are aware that there does not exist, other than our research study, a randomized, double blind study conducted to analyze the effect of this therapy. However, there have been some credible case studies and pilot studies on children with cerebral palsy (Paleg 1998, Barrett 1999, Montgomery et al. 1999, Packard 2000), published or presented at conferences. We may have reservations about the conclusions of these studies, but one thing does remain unchanged, they all showed similar improvements.

F. Is a low-pressure hyperbaric treatment effective?

We would like to restate that we are in agreement with the report of scientific advisory committee that there is no irrefutable proof illustrating that a HBO treatment at low pressure is effective on humans. Equally, there is no scientific proof showing that it is ineffective as there has never been any research on humans to evaluate this hypothesis. In our opinion, some of the clinical and experimental data deserve consideration.

-a recent study evaluating hyperbaric treatment with and without oxygen therapy in the treatment of cerebral vascular accidents in rats showed that: " Hyperbaric oxygen and, to some extent, hyperbaric pressure reduced ischemic brain damage and behavioral dysfunction."(Chang et al. 2000)

-A low-pressure hyperbaric treatment ( without oxygen) , the Gammow bag, is effectively used to treat cerebral edema suffered by some individuals when at high altitude, a condition known as "acute mountain sickness".(Austin 1998) It is estimated that the pressure reached with this bag is approximately .2 ATA. Recently, Heuser et al. reported a clinical improvement after ten hyperbaric treatments at a pressure of 1.3 ATA and in the cerebral SPECT scan in six patients presenting a toxic encephalopathy.

-Two double-blind studies were conducted on humans to evaluate the effectiveness of HBO therapy in the treatment of CVA in the acute phase. (Anderson et al. 1991, Nighoghossian and Trouillas 1995) The scientific advisory committee did not cite these studies. In both studies, the experimental group received a treatment of hyperbaric oxygen therapy at 1,5 ATA with 100% oxygen and the placebo group 1.5 ATA without oxygen. The study by Nighoghossian and Trouillas reported an improvement in both groups of subjects, with a greater improvement (however not statistically significant) in the group of patients that received the hyperbaric treatment with oxygen. In the study conducted by Anderson et al. improvement was reported in both groups, however the greater improvement was noted in the group that received hyperbaric therapy without oxygen (the difference was not significant statistically between the two groups). These patients were evaluated with a quantified neurological evaluation and a measurement of the volume of the cerebral infarct using repeated cerebral scans. The patients in the "placebo" group experienced more favorable results in these two measurements, suggesting that improbability of a placebo effect.

It is not up to us to evaluate in hindsight the results of these two studies. However, it would have been very interesting to compare the evolution of both groups with a control group without treatment. In our opinion, the results of both of these studies, especially the one by Anderson et al., support the possibility that a hyperbaric treatment at low pressure (1.5 ATA in that study) can have a therapeutic effect. Furthermore, the physiological effects of hyperbaric treatment are certainly more complex than solely the increase in partial pressure of oxygen (Buras 2000). It would be interesting to study the physiology of hyperbaric therapy with and without oxygen therapy.

G. Conclusion

The conclusion and the subsequent proposals are taken verbatim from what was proposed in May 2000. Our position remains unchanged with regard to the follow-up of our research project.

We are convinced that our work on this therapeutic approach must be pursued in order to identify the cause or causes of the reported improvements. It would be difficult to accept shelving the results of this study. We base our convictions on the fact that the improvement in mobility reported in these children after two months of hyperbaric treatment is similar to that measured after six months of intensive physical therapy (twice a week). Furthermore the children involved in this study showed improvements in language and neuropsychological evaluations as well as mobility. Finally, the improvements persisted for at least three months post-treatment (as verified scientifically).

It is our opinion that in order to properly investigate the different hypotheses raised, a double-blind study must be conducted where a true placebo would be compared to different treatments (oxygen alone, hyperbaric treatment alone and hyperbaric oxygen). It is clear that we could not recruit enough subjects for such a thorough study in Quebec. A multi-center Canadian or international study would have to be considered . This study would require many months or years to plan, finance and realize. Furthermore it would require hyperbaric chambers that are not available at the present time in the Quebec's public health care system. Finally, even though we did not definitively identify the cause or causes of the improvements, we are convinced that these results will encourage parents to continue to pursue hyperbaric treatments for their children. For these reasons, we recommend that at least one or more hyperbaric treatment centers remain open in Quebec.

H. Proposal to maintain one or more hyperbaric treatment centers in operation

For the above mentioned reasons we propose:

-to maintain one or more hyperbaric treatment centers in operation

-to make these centers readily available to treat patients presenting a chronic, non-progressive encephalopathy , at their own expense

These centers should assume, in part, the responsibility of systematically evaluating the patients undergoing hyperbaric treatment with a validated detailed questionnaire such as the PEDI.  Depending on their means, they should also evaluate mobility, language and cognition with as many subjects as possible. These centers should also agree to participate with any efforts to conduct a multi-centre Canadian or international study.

If one or more centers continue to operate and administer treatments in Quebec it would:

-avoid the need for parents to travel to Ontario or elsewhere (with all of the expenses and hardship it entails) in order to receive treatments often administered without any medical supervision nor pre and post treatment evaluation.

-allow us to continue to study the effects of this treatment. Although we are well aware that it would not be a double-blind study, it seems clear that the systematic evaluation process that we recommend is better than no evaluation at all.

-maintain the centers best prepared to participate in a multi-centre study due to their geographic location and their ability to treat many subjects at once.
 
Pierre Marois, physiatrist
Michel Vanasse, neurologist

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The Cornell Study
Dr Maurine Packard
Presented at the University of Graz 18th November 2000

Study Design
Our study was designed as a randomized, delayed entry trial of the effects of HBOT on children ages 1 to 5 years with moderate to severe CP. Enrollment criteria were 1) age between 1 and 5 years; 2) moderate to severe CP; 3) no evidence of brain malformation; 4) developmental delay of at least 33% in one area; 5) no active seizures for the previous 6 months.. The protocol consisted of 40 one-hour sessions HBOT at l.5 ATA. The sessions were scheduled twice a day, five days a week for four weeks. We did not design a double blind study, in which some children would receive placebo treatments, for several reasons. First, this was a pilot study to see if there was any evidence of benefit for these children. Second we purposefully enrolled children of various ages and disability levels to evaluate the efficacy of HBOT in a range of affected children. Third, as time in the chamber is very expensive, we wanted as much information about treatment effects as possible. Finally, it seemed unethical to have parents devote so much time and energy to a potentially ineffective treatment.
Demographics
The study population included 26 children, ages 15 months to 5 years, with cerebral palsy secondary to prenatal insults, premature birth, birth asphyxia, and post-natal hemorrhage. The subjects were enrolled at a rate of 4 per month and matched roughly to age and severity. The average age at enrollment was 30 months. The average motor age was 7.5 months; the average cognitive age and language age were both l2 months. Nine had cortical visual impairments.
Randomization
After the initial intake the children were randomly assigned to receive HBOT ( immediate group) or in 6 months (delayed group) The delayed group served: as an untreated control group.
Assessment
Intake assessments included a neuro-developmental assessment, Bayley II (cognitive assessment), Preschool language Scale (language assessment), the Peabody Motor Scales (an assessment of gross and fine motor skills), and Pediatric Evaluation of Disabilities Inventory (PEDI), a parental report of specific skill in mobility, self-care, and social interactions). Assessments were conducted at four time points: T1 - at enrollment; T2 - after the immediate group received treatment; T3 prior to the delayed group's HBOT, 5 months after enrollment; and T4 - after the delayed group's treatments. Two physical therapists who were blind to group status administered the Peabody and the parents completed tie PEDI at all four time points. Child psychologists blinded to group status performed the Bayley II and PLS at T1 and T3.
Results
Eleven of the 12 children in the immediate group completed the 40 HBOT sessions. The twelfth child developed complex febrile seizures and was dropped from the study. Twelve of 14 delayed children received a full course of treatment. Two subjects developed seizures and could not participate. Assessments from each time point were available on 9 subjects from the immediate treatment group and from 11 children in the delayed treatment group.
Side Effects
The only side effect of treatment was barotrauma to the middle ear. Nine children and 7 parents required ventilation tube placement or myringotomies.
Parental Diaries
The parents kept weekly diaries during the treatments. Over the month of treatments, 83% parents noted a marked improvement in mobility; 43% saw a marked increase in attention. and 39% reported a marked increase in language skills. Overall, there was some improvement mobility in 21 of 23 children.(91%), in attention in 18 of 23 subjects (78%), in language in 20 out of 23. (87%), and in play in 12 of 23 subjects (52%). One family saw no improvement and six families saw minimal improvement, a total of 30%. Five families (22%) reported major gains in skills and 11 families (48%) claimed modest gains.
Improvement in vision
Four of the 9 children (44%) with cortical visual impairment, including two infants with no functional vision, had improvement in their vision noted by the families, vision therapists and ophthalmologists.
PEDI Results
There was a significant difference (p<0.05) in the improvement of scores on the mobility sub-domains of the PEDI for the time period T2 minus TI in favor of the immediately treated group. For the period T4 minus T3, there was a trend favoring the recently treated delayed group (p< 0.058). For the social function sub-domain of the PEDI, there was a trend favoring the more recent treated group.
Blinded Assessments
The two groups were compared on changes in their Peabody scores for T2 minus T1 and T4 minus T3 and for changes in the Bayley II and PLS scores for T3 minus T1. There was no statistical difference in the change scores on any of the blinded assessments.
Discussion
There are several reasons why our blinded assessments did not show a significant difference while parental reports and observations during therapy saw gains. First, our sample size was quite small and only very dramatic changes would be detected. Second, not all the children were cooperative and happy during their evaluations, we had a student, blind to the group status, review the videotapes of the PT sessions and rate the child's behavior. There was a strong correlation between the child's mood and score; happy kids did better. Third, the instruments we chose as assessment tools we insensitive to the changes that were reported by the parents and observed by the unblinded staff.
The improvements in motor function did not translate into immediate functional gains. Most development tools available required motor dexterity and expressive language skills, areas specifically affected by CP. A better, more sensitive evaluation would involve a skilled professional observing the child at home or in school over a several hour period.
Conclusion
Our conclusion is that, for some children with moderate to severe CP there is evidence that HBOT improves motor skills, attention, language, and play. For some, an increase in vision was noted. These are not miraculous changes. These children all still have CP, but there are substantial improvements.
In follow up interviews over 6 months, it was found that the changes in spasticity were most likely to diminish over time, but the improvement in attention, language and play remained. This increase in attention is particularly important for children must be aware their environment in order to learn. This represents a direct impact on cognitive functioning. The main differences between HBOT and traditional therapies are the rapid gains over time: and the impact on cognitive skills which, in general, are not improved by PT, OT, and speech therapies. Whether these changes are the direct result of increased levels of oxygen or the intensive contact with the parent or adult in the chamber or other a combination of factors should be the focus of further study.

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CLINICALLY OBSERVED REDUCTION OF SPASTlClTY IN PATIENTS WITH
NEUROLOGICAL DISEASES AND IN CHILDREN WITH CEREBRAL PALSY FROM HYPERBARIC OXYGEN THERAPY.
MACHADO, 1.J. Neurological Advisor of "Centro Brasileiro de Medicina Hyperbarica" - Rua Bento ale Andrade, 70, Sao Paulo, Brazil.
Our personal experience with hyperbaric oxygen therapy (HBOT) in patients with neurological diseases started in 1979. From that time we have used it as an adjunct to physiotherapy in the rehabilitation of these patients.  In the first four years, we worked with patients suffering from ischemic cerebral vascular accidents, and verified that the clearest and most common effect of HBOT during treatment and soon after it was a reduction of spasticity. This was obvious clinically and functionally in hemiplegic patients and preceded motor improvements. During 1984-85, we accumulated experience with the HBOT in other pathologies, including head injury, anoxic-encephalic disorders and Multiple Sclerosis patients. The same results were found.
We then decided to investigate the effect of HBOT on children with cerebral palsy- another predominantly spastic disease. In 1985, we started working as neurological advisors for the "Centro Brasileiro de Medicina Hyperbarica" (CBMH) and selected a group of 10 children with spastic cerebral palsy who may benefit from HBOT, as they had respiratory difficulties, bronchitis, repeated pneumonia and bronchial asthma. An HBOT treatment program was devised for this group and we observed the same reduction of spasticity in these patients. Also there was improved respiratory function, the bronchial complications disappeared and this was confirmed clinically.  This initial success then led to other problems as the physiotherapists sent us other cases to be treated.

The parents of affected children contacted us to try HBOT on their children. We let them know that we could find no references to this in our literature, and such a therapy, while harmless, could be unnecessary or even present temporary side effects. However, despite this, they insisted on trying it.  We then looked for assistance from other specialists, including those in our University, in order to conduct scientific research on the matter, but had no support.

The CDMH is a private medical office, one of few hyperbaric medicine centers in Brazil. We have commercial or corporate participation in the center but we have since had to interrupt our collaboration, because of problems generated by accepting these patients.  We found that HBOT is little known in Brazil and is considered to be "alternate medicine" by physicians, who only recognize its merit in respect to the treatment of gas gangrene.  From January 1985 to April 1989, 230 patients with Cerebral Palsy were treated with a series of HBOT (20 sessions of 1 hour). In 218 (97.78%) patients, there was a clear reduction of spasticity (nearly 50% less). Frequently, clonus or the Babinski sign would disappear, with better plantar support and the abolition of the leg "scissoring."  Only 12 patients (5.21%) remained practically unchanged. They were extremely severe cases, with profound cerebral atrophy.

Follow-up of patients over a period of 6 or more months after HBOT was only possible in 82 (38.65%) patients as most of them did not live in Sao Paulo. We noticed that 62 (75%) patients had a persisting reduction of spasticity and better motor control. In addition, the parents reported other types of improvement, such as a better balance, the child being more attentive, more "intelligent" with a reduced frequency of convulsions and episodes of bronchitis. Perhaps we have been encouraged by the patients, to place attempts at therapy before research, but we do believe that oxygen at higher dosage plays an important role in the rehabilitation of neurological patients, and has a favorable effect on neurological development in children. We suspect subsequent studies will confirm this  (Complete report included in MUMS HBO packet.)  Information obtained from:  MUMS National Parent-to-Parent Network (newsletter # 71).

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The Recoverable Brain in Certain Pediatric Patients

R. NEUBAUER, J. USZLER, and P. JAMES

Ocean Hyperbaric Center, Lauderdale-by-the-Sea, FL (USA)
* Department of Nuclear Medicine
Santa Monica-UCLA Medical Center, Santa Monica, CA (USA)
** The Hyperbaric Oxygen Trust
Forest Row, England, (UK) and the University of Dundee, Scotland

SUMMARY

Anoxic-ischemic encephalopathy and traumatic brain injury in children are examples of devastating conditions, which can be responsible for decades of disability. A regimen of single photon emission computerized tomography (SPECT) scanning and hyperbaric oxygen (HBO) treatment is now available to identify recoverable (stunned or dormant) brain tissue and potentially improve function in such patients. A baseline scan is performed. A challenge with hyperbaric oxygen ( 1.5 ATA, I Hr. 1-20 txs) is given and the scan is repeated. Observation of increased flow is indicative of increased metabolism since the tracer crosses the blood brain barrier. Such positive changes seen in the SPECT are frequently paralleled with clinical improvement. PT, OT, speech, biofeedback, occasional herbal medications are used as part of a multi-disciplinary brain repair approach. Three such cases will be presented; two cerebral palsy (M ages 3 and 4) and an F age 8, with closed head injury.

MATERIALS AND METHODS

The protocol is one that had been previously published (1). It involves Sequential SPECT (brain) functional imaging with an HBO challenge of (I hr x 1.5 ATA) 1-2 times a day in a monoplace hyperbaric chamber (dickers Ltd, Hampshire, UK). 1020 exposures to HBO were performed to ascertain the possibility of recoverable brain tissue. The second scan was done within two hours following the HBO exposure prior to the second scan. The radioactive tracer used was Tc 99m dl

8th INTERNATIONAL CHILD NEUROLOGY CONGRESS

Ljubljana, Slovenia 13-18 September 1998

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HYPERBARIC OXYGEN THERAPY FOR CEREBRAL PALSY CHILDREN

Philip James MB ChB, DIH, PhD, FFOM, Wolfson Hyperbaric Medicine Unit, The University of Dundee, Ninewells Medical School, Dundee DD19SY.

To significantly increase the delivery of oxygen delivery to the tissues requires the use of hyperbaric conditions, that is, pressures greater than normal sea level atmospheric pressure. When tissue is damaged, the blood supply within the tissue is also damaged and too little oxygen may be available for recovery to take place. Hyperbaric medicine is not taught in most medical schools and is often dismissed by doctors as "alternative" medicine, but it is drugs that are alternative. Some raise fears about toxicity but in practice, this is not a problem. More is known about oxygen and its dosage than any pharmaceutical.

There is no more important intervention than to give sufficient oxygen to correct a tissue deficiency but, unfortunately, oxygen is only given in hospital to restore normal levels in the blood. The increased pressure has no effect on the body, although the pressure in the middle ear and sinuses in adults has to be equalized. More oxygen may help many children with cerebral palsy, but it is NOT a cure. There are some obvious questions to be answered: When does the damage occur? Ultrasonic scanning of the brain has shown that in most children the events which cause the development of cerebral palsy (CP) occur at the time of birth, 1 although it may be many months before spasticity develops.2 where does the damage occur? The areas affected in CP are in the middle of the hemispheres of the brain and one side or both sides may involved.

These critical areas, called the internal capsules, are where the fibres from the controlling nerve cells in the gray matter of the brain pass down on their way to the spinal cord. In the spinal cord, they interconnect with the nerve cells whose fibres activate the muscles of the legs and arms. Why does the damage occur? Unfortunately, the internal capsules have a poor blood supply, shown by the frequent occurrence of damage to these areas in younger patients with multiple sclerosis and in strokes in the elderly by Magnetic Resonance Imaging (MRI). When any event causes lack of oxygen the blood vessels leak, the tissues become swollen and there may even be leakage of blood. The increased water content, termed edema, reduces the transport of oxygen. This applies to any tissue, but especially to the brain where a sufficient quantity of oxygen is vital both to the function and, in children, its development. What causes paralysis and spasticity to develop? When the controlling nerve cells in the brain are disconnected from the spinal cord, the signals to the arms and legs cannot pass and the ability to move is lost. Eventually, because the nerve cells in the spinal cord are separated from the control of the brain, they send an excess of signals to the muscles, causing the uncontrolled contractions known as spasticity.

The areas carrying the nerve fibres to the legs are the closest to the ventricles of the brain where the blood supply is poorest3 so the legs are the most commonly affected. The is called diplegia, to indicate that the problem is in the brain and distinguish it from paraplegia where the damage is in the spinal cord. Why is spasticity delayed? This crucial question is, at present, not adequately explained or even raised. Children who develop spasticity often appear to develop normally for several months and then lose function gradually. Because in many children there is voluntary movement for a time after birth, the connections must still be intact. Why then are they lost allowing spasticity to develop? The answer almost certainly is due to the failure of the coverings of the nerve fibres, known as myelin sheaths, to develop. This evidence has come from MRI.2 Myelin sheaths envelope the nerve fibres like a Swiss roll in order to increase the speed of impulse transmission.

Myelination normally begins about a month before birth and progresses to completion by the age of two. If there is, tissue swelling in the mid-brain the delicate cells that form myelin die and the nerve fibres, left exposed, slowly deteriorate with the ultimate development of spasticity. What may be possible? Loss of function in the brain can be either due to tissue swelling, which is reversible, or tissue destruction, which is not. The recoverable areas can now be identified by a technique called SPECT imaging. The initials stand for Single Photon Emission Computed Tomography. It can demonstrate blood flow, which is linked to metabolism of the brain, which is, of course, directly related to oxygen availability. By giving oxygen at the high dosages possible under hyperbaric conditions, areas which are not ''dead but sleeping'' can be identified. This phenomenon has been discussed for many years in stroke patients and authorities have even stated that the critical parameter is not blood flow it is oxygen delivery.4 Under normal circumstances, blood flow and oxygen delivery are inextricably coupled, but the use of hyperbaric conditions can change this situation.

Tissue edema and swelling may persist in, for example, joints, for many years and SPECT imaging has now revealed that this is true in the brain.5 What does hyperbaric mean? It means a pressure greater than normal sea-level atmospheric pressure. Atmospheric pressure at sea level varies with the weather and on a high-pressure day, more oxygen is available to the body. Aches and pains may be worse on a low-pressure day because of the reduction of oxygen pressure. A hyperbaric chamber allows much more oxygen to be dissolved in the blood. An indication of the power of this technique is that at twice atmospheric pressure breathing pure oxygen the work of the heart is reduced by 20%. So much can be dissolved in the plasma that life is possible for a short time without red blood cells. The research behind the development of hyperbaric oxygen therapy has been undertaken by doctors involved in aviation, space exploration, and diving. This critical information is not yet taught in our Medical Schools, despite many thousands of published articles including controlled studies in many conditions. Are there dangers? The only risk with hyperbaric conditions properly supervised is to the eardrum, just as when aircraft - which are hyperbaric chambers - descend. There are limits to oxygen delivery, for example, the very high pressures used in diving can cause convulsions, but the Chinese have shown that epilepsy is actually treated by hyperbaric oxygen therapy at lower pressures. There is no evidence of either eye or lung toxicity at 1.5-1.75 atm abs.

References:

  1. Pape KE, Wiggleworth JS. Hemorrhage, ischemia, and the perinatal brain. Clinics in developmental medicine. .Nos. 69/70 William Heinemann Medical Books, London, 1979.
  2. Dubowitz LMS, Bydder GM, Mushin J. Developmental sequence of periventricular leukomalacia. Arch Dis Child 1985;60:349-55.
  3. Takashima S, Tanaka K. Development of cerebrovascular architecture and its relationship to periventricular leukomalacia. Arch Neurol 1978;35:11-16.
  4. Astrup J, Siesjo BK, Symon L. Thresholds in cerebral ischemia; the ischemic penumbra. Stroke 1981;12:723-25.
  5. Neubauer RA, Gottlieb SF, Kagan RL. Enhancing idling neurones. Lancet 1990;336:542.
  6. Muraoka R, Yokota M, Aoshima M, et al. Subclinical changes in brain morphology following cardiac operations as reflected by computed tomographic scans of the brain. J Thorac Cardiovasc Surg 1981;81:364

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HBO in the Treatment of Asphyxia in New-born Infants
Delivered by Caesarean Section.

E.A.Lantsev Institute of Obstetrics and Gynaecology, Leningrad, USSR.

The effect of HBO was studied on 87 on new-born infants delivered in asphyxia by caesarean section. HBO was started within 5 minutes of birth. For the first 15 minutes at a pressure of 3 ata , then at 1.5-1.3 ata for 1.5-2 hours. The long-term results were followed in 33 infants for 3-10 years. In only one child, at the age of 3.5 years, was epilepsy and deaf-mutism revealed. The remaining children developed normally. The inclusion of HBO in the resuscitation of infants delivered by caesarean section with asphyxia greatly reduces the consequences of neonatal asphyxia.

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HYPERBARIC OXYGEN THERAPY IN THE PREVENTION OF DELAYED DETERIORATION AND CEREBRAL PALSY FOLLOWING PERIVENTRICULAR DAMAGE IN THE NEWBORN

Phillip B James, Wolfson Hyperbaric Medicine Unit, Ninewells Medical School, The University of Dundee, Scotland.

Introduction

The introduction of routine ultrasound screening in premature neonates can reveal evidence of cerebral damage prior to the development of clinical signs. Although far from being a sensitive tool, ultrasound can demonstrate the gross forms of periventricular hemorrhage and edema that characterize this form of brain damage. The mechanisms suggested for periventricular damage in premature neonates include hypertension and cerebral trauma,1 but it is thought that these factors are only responsible for some of the cases.

Circumstantial evidence suggests that placental embolism and the passage of emboli through the patent foramen ovale may be a factor, but this is controversial2. All of the mechanisms suggested are likely to be associated with tissue hypoxia.

It has been established clinically that many brain damaged infants may develop normally for some months, before the spasticity characteristic of cerebral palsy becomes apparent. In the first period, there is a clear evidence from the responses of the child that the upper motor neuron and the long tracts are operating and able to active the lower motor neurons.

Why then should the spasticity develop after a delay? From pathological studies it would appear that in most premature infants the motor cortex is not affected and the deterioration is in the fibres of the pyramidal tract.1

At the level of the internal capsule, the tracts pass close to the cerebral ventricles, the area affected in periventricular leucomalacia. The vasculate of the area is immature in infants of about 30 weeks gestation as demonstrated by microangiography.3 The development of hemorrhage at birth is unequivocal evidence of gross blood-brain barrier damage. It would seem likely that continued blood-brain barrier dysfunction and the resultant edema leads eventually to degeneration of the motor fibres in this area.

Evidence from the anatomical disposition of the fibres in the internal capsule accords with this view, as the legs are more commonly affected than the arms.

A further factor is likely to be related to failure of the myelination.

Normal myelination begins about two weeks before term and spreads from the brain stem. It is usually complete, including the cerebral hemispheres, by the end of the first year of life. If there is significant edema from the blood-brain barrier dysfunction in the internal capsule area, myelination is unlikely to take place, leaving the axis cylinders exposed and vulnerable. Secondary degeneration may then take place and spasticity of the appropriate limb develops. (NB What about sensory function) This accords with the developmental sequence from the correlation of the ultrasound, clinical and nuclear magnetic resonance findings described by Dubowitz et al.4 In a study of two survivors of triplets, M.R.I. has demonstrated failure of myelination in the child with periventriuclar leucomalacia. An important difference between preterm and term infants has been pointed out by Larroche in 1977.5 In pre-term infants, periventriuclar leucomalacia is often the only brain lesion present, but, in full term infants, cerebral damage is usually associated with evidence of neuronal necrosis.

Case Report

On the 23rd December 1987, identical twins (1435 and 1358 gms respectively) at 29 weeks gestation were born by emergency Caesarian section, after the mother went into premature labor. Ultrasound scanning on the third day post-delivery revealed a periventriuclar hemorrhage in the left cerebral medulla of the larger twin. A repeat scan on day 15 showed extension of this lesion and damage also on the right side. The parents were informed that the child would almost certainly develop spastic quadriplegia, visual defects and mental retardation. It was also felt unlikely that she would ever be able to sit up. Two and a half months post-delivery, just before discharge from the hospital, there was a mild hydrocephaly, but all four limbs were moving normally. The baby was feeding and gaining weight.

The child left hospital at the beginning of March 1988. In view of the very bad prognosis and the undoubted presence of cerebral edema, it was decided to see if hyperbaric oxygen therapy would assist in the maturation of the medulla and hopefully, by preserving the long tracts, avoid the development of spasticity. As the child was at term and normal retinal development had taken place retrolental fibroplasia would not be likely to occur. Therapy consisted of 1 hour sessions at 2 ATA in a monoplace chamber for six days a week for three months, five days a week for three months and finally three session a week to nine months. A plastic bowl was used for the head of the baby and a polythene sleeve enclosed in the body. A continuous flow of oxygen was provided from a Scott regulator on free flow and the chamber flushed regularly.

A Spitz valve was inserted at six months to relieve intracranial pressure.

Audiometry indicated deafness in the right ear at his time. At eighteen months there was no sign of spasticity, but recently therapy was restarted because of evidence of mild spasticity in the right leg. The child is alert and has some co-ordination, although well behind her twin in development.

The therapy was conducted on a single blind basis as none of the medical, nursing or paramedical staff were aware of the hyperbaric oxygen therapy being used. Although, even at this state, it is by no means certain that the child has escaped the gross consequences of cerebral damage, from the progress made to-date it would appear unlikely that dramatic deterioration will occur at this stage. The child is very alert and responsive. Head control is developing slowly. She is beginning to crawl and is able to place objects in her mouth.

Discussion

Unfortunately, it has not been possible to use magnetic resonance imaging to follow the extent of myelination in this child. Young children who sustain damage to the cerebral medulla from micro-embolism in cardiac survey also develop enlargement of the cerebral ventricles demonstrable on computed tomography.6 however it is of paramount importance to recognize that this has been found to be reversed with regrowth of medullary tissue over a period of 6-11 months. The most likely explanation of this phenomenon is that it is due to remyelination, as most of the volume of the cerebral medulla is due to the bulk of the myelin sheaths. In adults, blood-brain barrier damage in the periventriuclar area, where the veins draining the area of the medulla run parallel to the wall of the lateral ventricle, leads to the characteristic demyelination of multiple sclerosis.7

The condition often progresses to a leucomalacia with ventriuclar dilatation identical to that seen in periventricular leucomalacia in the infant. From pathological studies and from M.R.I. there is unequivocal evidence of edema, which inevitably limits oxygen transport. Although mild degrees of hypoxia appear to act as a stimulus to capillary neogenesis, severe hypoxia in the words of J.S. Haldane8 not only stops the machine, but also wrecks what we took to be the machinery. In the developing infant this will impede the vascularisation of this critical area. Intermittent elevation of the partial pressure of oxygen under hyperbaric conditions not only improves the immediate oxygen availability, but also reduces tissue hydrostatic pressure and allows the resolution of edema. On scientific grounds there would appear to be an excellent rational for the use of hyperbaric oxygen in the prevention of delayed deterioration in damage to the cerebral medulla in the preterm infant. Clearly prevention is better than cure and monitoring with magnetic resonance may allow the effect to be demonstrated in real time. Normobaric oxygen supplementation has already proven of value in the prevention of morbidity in babies with intra-uterine growth retardation, where there has been proven evidence of hypoxia.

Finally, hyperbaric oxygen has been shown to be of value in a case of foetal distress, probably associated with premature placental separation and amniotic fluid embolism.9 A mother close to term who had been admitted for observation after an antepartum hemorrhage collapsed with a left hemiplegia. She rapidly lost consciousness and developed stertorious respiration. Oxygen at normal atmospheric pressure produced only marginal improvement in her condition and, because of severe fetal distress, a Caesarian section was performed at 2 ATA in a multiplace chamber. It is notable that, despite the use of hyperbaric oxygen, the uterus was noted to be slightly cyanosed and the maximum arterial oxygen tension achieved was 490 mm Hg. However the fetal heart rate which was 220 and irregular before compression, fell to 165 and became regular. A normal live female infant was born with an Apgar score of 9. There would appear to be reasonable grounds to suggest that all deliveries in premature labor should be undertaken under hyperbaric conditions to protect the fetus from hypoxia during this critical period. Apparently this is undertaken by colleagues in Russia and may be important in the prevention of the blood-brain barrier damage that leads to periventriuclar haemorrhage and leucomalacia.

It is clear that hypoxia complicated many facets of obstetric and neonatal practice. The rapid reversal of hypoxia by hyperbaric oxygen in limited the extend of tissue damage may prove to be critical to the reduction of many distressing forms of infant morbidity.

References

  1. Pape KE, Wigglesworth JS. Haemorrhage, ischaemia and the perinatal brain. Clinics in developmental medicine. Nos 69/70 William Heinemann Medical Books, London, 1979.
  2. James PB. Placental embolism : a possible cause of respiratory distress and cerebral damage in the newborn. Submitted to : Med Hypoth 1989.
  3. Takashima S, Tanaka K. Development of cerbrovascular architecture and its relationship to periventriuclar leukomalacia. Arch Neurol 1978;35:11-16.
  4. Dubowitz LMS, Bydder GM, Mushkin J. Developmental sequence of periventricular leukomalacia. Arch Dis Child 1985;60:349-55.
  5. Larroche JC. Developmental pathology of the neonate. Amsterdam: Exerpta Medica 1977.
  6. Muraoka R, Yokota M, Aoshima M,et al. Subclinical changes in brain morphology following cardiac operations as reflected by computed tomographic scans of the brain. J Thorac Cardiovasc Surg 1981;81:364-69.
  7. Allen IV. The pathology of multiple sclerosis: fact, fiction, and hypothesis. Neuropath Appl Neurobiol 1981;7:169-82.
  8. Haldane JS. Respiration. Yale University Press, 1923.
  9. Ledingham I McA, McBride TI, Jennett WB, et al. Fatal brain damage associated with cardiomyopathy of pregnancy with note on Caesarian section in a hyperbaric chamber. Br Med J 1968;4:285-87.

Presented at the 2nd International Hyperbaric Oxygen Society Conference Kos 1988

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New Hope for the Neurologic Damaged Child, Cerebral Palsy, Anoxic Ishemic Encephalopathy and Traumatic Brain Injury.

A new era of therapy is now advancing for the treatment of neurologically disabled children at the Ocean Hyperbaric Center. In the United Kingdom there is a charity for CP (cerebral palsy) and the TBI (traumatic brain injury) child utilizing HBO (hyperbaric oxygen). We understand that a new trial for the same is beginning at McGill University in Montreal.

CP a catchall term describes brain injuries either in utero, at the time of delivery, or in the post partum period. These injuries cause a type of damage to the brain by trauma or by cutting cerebral circulation producing an AIE (anoxic ischemic encephalopathy).

The reason for not giving oxygen (normobaric) to the hypoxic (low oxygen) neonate or premature baby is that surface oxygen may cause a type of blindness called retrolental fibroplasia. The use of hyperbaric oxygen however, does not produce this same effect.

Many children hypoxic at birth are not given HBO to correct the condition with the exception of South America and Russia. The incidence of CP is dramatically less in those areas than in the United States. (Again HBO does not produce the complication of blindness).

Thousands of children have a near drowning episode each year. This leads to a permanent neurologic damaged state ranging from a persistent vegetative coma to being unable to return to society.

TBI may occur at birth, from the shaken baby syndrome, to the battered child, or due to the automobile accidents, etc. Such episodes produce an internal type of brain injury, which again results in many years of care and lack of normal life.

New techniques with brain imaging, especially SPECT (single-photon emission- computed tomography) clearly show the functional status of the brain at a point and time. HBO, that is 100% oxygen at greater than surface pressure, which is administered to children in small sequential doses of 1.5 ATA (about 18 feet below sea level), one hour each, one to two times a day for multiple treatments, depending upon the response. Sequential SPECT scan not only measures blood flow, but also metabolism. Such data has been useful in determining the dose* of HBO. As the SPECT scans improve, frequently, so do the children. There is about a 90% correlation.

All modalities of Speech, OT, PT, biofeedback and herbal remedies depending on the age are also utilized as a multi disciplinary brain repair regime.

More recent innovations include the use of human growth hormone and alphalearning, which is a composite of biofeedback, audio-visual, and EEG brain balancing technique.

A summary of the effects of HBO both in acute and semi-acute and long-term neurologic conditions are as follow:

HBOT reduces any pressure within the brain caused by swelling, restoring the functions of the blood brain barrier and cell membrane. It neutralizes toxic products in the brain, and over a period of time, enhances growth of new blood vessels. It also acts as a scavenger of free radicals and promotes internal cleaning of debris. HBO also reduces the stickiness of blood products (white blood cells and platelets), and makes oxygen available for use without energy transfer (when the hemoglobin carries oxygen, it requires energy to deliver to the tissue spaces). With HBO the free oxygen is available immediately for metabolic use.

Theoretically the use of HBOT in CP, TBI and in the very young will actually give the brain a jump-start. It also produces an ideal internal environment for the growth of new brain tissue.

There are however many other problems in the neo or perinatal which may be amenable to HBOT. A) Microbial origin (German measles, syphilis, herpes, hepatitis, meningitis, cytomegaly, listeriosis and toxoplasmosis), B) toxicity (thalidomide, purimotamine, psychotropic, carbon monoxide, alcohol abuse and smoking), C) metabolic disturbances (diabetes, malnutrition, hypotension, hemorrhages and eclampsis).

It is hoped that this new innovative approach with scientific documentation will become more available and such children will be treated at the time of injury, rather than waiting for permanent devastating changes to occur.

The following cases represent several of the many cases treated to date at the HBO center. Several hundred cases, with encouraging results, are now under treatment in the UK sponsored by the Hyperbaric Oxygen Trust, (a charity that is dedicated to the treatment of CP in the brain-injured child).

*(i.e. depth of pressure, length of treatment, frequency and total amount of treatments)

JAIN KK. Textbook of Hyperbaric Medicine. 2nd revised edition USA, Hogrefe & Huber, 1996.

Neubauer RA, Walker M. Hyperbaric oxygen therapy. USA, Avery, 1998.

Machado JJ. Reduction of spasticity, clinically observed in patients with neurological diseases, submitted to hyperbaric oxygen-therapy specially children with cerebral palsies. Presented at: New Horizons in Hyperbaric Medicine, Orlando, Florida, April 26-30, 1989.

Zerbini, Solonay. Personal communication. (city), 1998.

Cases:

DW (Figs 1A & 1B): 3 year old white male suffered perinatal hypoxic ischemic encephalopathy with renal failure consisting of acute tubular necrosis, thrombocytopenia, sepsis, respiratory insufficiency, hypovolemia and apnea related to seizure disorder. The CT scan showed progressive cortical atrophy.

It is remarkable that this patient survived with the multiple illnesses. The patient received 21 treatments of HBO and is now able to sit up, hold a cup for the first time in his life and is more attentive. He is much more alert, makes new vocal sounds, is more aware of his surroundings and is beginning to grab at everything. These changes parallel SPECT scan imprint. It is hoped that future HBO treatments will be available with all types of supportive therapy.

DS (Figs 2A & 2B): 4 year old white male was seen with a severe traumatic birth, which caused a left mid cerebral rupture and then further developed Lennox-Gastaut syndrome (severe seizure disorder). He was seen four years later and had been continuously receiving PT, OT, and SP three days per week.

He had done well on a ketogenic diet and developed the ability to chew. On the daily scale of infant development, mental status, he was less than 50 (normal = 90-110) basically with about an eight month level. He was seen with a spastic paraplegia, barely able to ambulate with assistance. The patient received 92 HBO treatments and improved dramatically. The patient has become very much more active, following more commands, beginning to use his right hand to hold things, responds to his name and now able to run, but still with a slight limp.

TB (Figs 3A & 3B): 8 year old girl in motor vehicle accident, closed head trauma and 3 mo coma, total occlusion of the R mid-cerebral artery and spastic hemiparesis on the left. She wore a brace, had severe limp, speech deficits and was slow mentally, although attempting to go to school. SPECT scan showed an extensive deficit or complete infarct with the R middle cerebral artery distribution. She was seen 11 months post incident. SPECT scan before and after HBO showed substantial improvement. She was only able to stay for 24 treatments, but with HBO along with therapy, she was able to remove the brace. She became sharp mentally and was able to almost enter into full activities with other children. She was most pleased to become more socially accepted by her peers.

From: Neubauer RA, Uszler JM, James PB. Hyperbaric oxygenation: The recoverable brain in certain pediatric patients. (conference)

Case EC. A 2 1/2 year old boy was seen 1 1/2 months after a near-drowning episode. The child hit his head and fell into the swimming pool. It is not known how long he was submerged. The family was told that the child was blind and he presented in a persistent vegetative state with severe spasticity on the left side and hypomobility of the right leg. He was fed by PEG tube. Initial SPECT imaging showed extensive and symmetrical deficit throughout frontal, temporal, parietal and occipital lobes. After three treatments with hyperbaric oxygen therapy the patient began moving more, trying to speak, and "acting up" when angry. The patient began crying with tears for the first time after 16 treatments. After 26 treatments the patient was smiling, much more alert, laughing, crying, sleeping much better and laughing while dreaming. Following 34 treatments the patient was more aware, developing much more eye contact and was clearly not blind. To-date the patient has received 199 treatments and now sees clearly, is speaking bi-lingually, standing and taking a few steps. He is now able to eat and drink normally. He was given back a life.

From: Neubauer RA, James PB. Cerebral oxygenation and the recoverable brain. Neuro Res: 20 (Suppl 1) S33-S36, 1998.

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Pediatric Cerebral Palsy treated by 1.5 ATA Hyperbaric Oxygen Therapy

A pilot study
Barrett, Kevin M.D., et al.
(Professor of Hyperbaric Medicine,
University of Texas Medical Branch, Galveston, Texas).

Five children, average age 41.8 months, were treated with 1.5 ATA Hyperbaric oxygen therapy (HBOT) for a total of sixty treatments administered for one hour daily, five days per week.

The authors conclude that Hyperbaric oxygen therapy effected improvements in tests of gross motor and fine motor function and decreased Spasticity. Results were measured by the modified Ashworth Spasticity score in patients with chronic cerebral palsy.

Functional reorganization in the visual cortex is suggested by the reappearance of visual evoked potentials, where none had existed before HBOT.
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"Hyperbaric Oxygen Therapy for children with Cerebral Palsy."

Cronje, F.
SOUTH AFRICAN MEDICAL JOURNAL, 1999, 89(4): 359-60. Letter.

Subjective and objective clinical improvements have been reported anecdotal in almost all children treated with Hyperbaric oxygen throughout the world, including South Africa, with no adverse effects. Possible mechanisms by which Hyperbaric oxygen therapy may benefit these children include:

  1. Normalization of glucose metabolism by injured brain cells - positive effects continue even after the oxygen exposure has ceased.
  2. Hyperbaric oxygen has a dramatic effect on reducing tissue swelling and is used in the treatment of crush and traumatic injuries for that reason.
  3. The improvement in motor function and decrease in Spasticity in chronic brain injury and CP seems to be related to a "recanvassing" of idling neurons in the affected area of the brain - neurons that survived the original hypoxia or trauma but have not resumed their former electrical activity due to com-promised blood supply and oxygen delivery.


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Clinically Observed Reduction of Spasticity in Patients with Neurological Diseases and in Children with Cerebral Palsy from Hyperbaric Oxygen Therapy

Machado, J.J. Neurological Advisor of "Centro Brasilerio de Medicina Hyperbarica" - Rua Bento de Andrade, 70, Sao Paulo, Brazil.

The author presents case studies of 230 children with spastic cerebral palsy who received Hyperbaric oxygen therapy (20 sessions of 1 hour each).

The author observed a significant reduction in Spasticity and improved respiratory function in 94%, and continued reductions in Spasticity, improved motor control and a reduction in convulsions and episodes of bronchitis in 75% of those followed for 6 months.
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The effect of Hyperbaric Oxygen Treatment on Functional Outcomes in Children with Cerebral Palsy: A Single Case Description

Paleg, Virginia, M.S., P.T.
(The Hospital for Sick Children,Washington, D.C., 20017).

The author describes a case study of a 15 month old diagnosed with Level V (Severe) spastic quadraparetic cerebral palsy, cortical vision impairment, and seizure disorder.

The boy was treated with Hyperbaric oxygen at 24 mmHg for one hour for 33 treatments. Immediately following HBO, the subject appeared to have gained the skills of lifting his head up in sitting and prone on elbows, and the ability to sit with minimal assistance. Other changes noted by parent and therapist include an increase in endurance (child now holding up head in prone on elbows greater than 10 minutes) and head righting (child no longer gets stuck in cervical extension, but can right his head independently).

The subject is, at this time, 3 months post HBO and reportedly continues to make gains. He is vocalizing more, is more alert, has improved passive and active range of motion, is more responsive visually, and opens his hands when reaching.
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Proceedings of the VIIth International Congress in Hyperbaric Medicine held in Moscow in 1981.
HBO in the Treatment of Asphyxia in New-born Infants Delivered by Caesarean Section.
E.A.Lantsev Institute of Obstetrics and Gynaecology, Leningrad, USSR.

The effect of HBO was studied on 87 on new-born infants delivered in asphyxia by caesarean section. HBO was started within 5 minutes of birth. For the first 15 minutes at a pressure of 3 ata , then at 1.5-1.3 ata for 1.5-2 hours. The long-term results were followed in 33 infants for 3-10 years. In only one child, at the age of 3.5 years, was epilepsy and deaf-mutism revealed. The remaining children developed normally. The inclusion of HBO in the resuscitation of infants delivered by caesarean section with asphyxia greatly reduces the consequences of neonatal asphyxia.

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TESTIMONIALS FROM PARENTS......Taken from various Email Forums.  Some are advising other parents or adults and answering questions.  They were selected simply because they are telling about the results they achieved using HBOT.  Keep in mind, it is very unlikely you will see falsified testimonials due to the cost of HBOT.  When something is expensive, you will not see good testimonials unless good results were achieved.   The Email addresses and contact info has been removed unless permission was given to include the info.  Some names were replaced by **** because I was not certain if parents would mind or not.  If you would like your testimonial included here please email me at rhartsoe@skybest.com.  Others would enjoy reading them and it may help them make the decision on whether to include HBOT or not.
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Hi Amy!
How old is your daughter? My son is 1 yo and hasn't been officially been diagnosed with CP but I assume he will be. He suffered loss of oxygen at birth due to a uterine rupture, causing brain damage. His motor skills are extremely affected. He also is g-tube fed and has seizure disorder. He doesn't have full head control yet, doesn't' sit-up, or crawl/walk either.
Christian is his name and he started Hyperbaric treatments in May/June of this year, he has had 40 treatments. We went to Miracle Mountain in Creston, NC. The HBOT helped his suck/swallow, he is much more alert, his hyper-toned extremities are much more limber, his head control is progressing, his eye movements are more controlled, less nastagma, focus' better on objects occasionally, he is much more vocal, in the last week he has started making a "goo" noise. This is very exciting for us and for him. We are scheduled to return to MM in October.
I hope this helps you. I don't know where we would be without HBOT. I don't want to know. He seizures still are not controlled by medication, we are praying to GOD that this next round of HBOT will help that also.
God's Blessing,
Jodi Schiel

HBOT is amazing! The nastagma became less about 1/2 way through the treatments. His last treatment was in June, I believe the 22nd.
Also, Christian used to have a A-symetrical bottom lip, It was crooked, looked like the once side was sucked in all the time. I swear, that after the very Fiirst treatment day, his lip has been straight since. I couldn't believe my own eyes. I thought I was imagining things.
Keep in touch, I will pray for you two also!
God's Blessings,
Jodi
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We have done nearly 100 treatments. We did a set of 40, doing two a day for
20 days with one two-day break in there. We saw amazing results. Bethany was
8 at the time. She had just had a shunt blockage, a very bad one and was not
walking, talking, anything. After the forty treatments, she was walking
again, better than ever and had begun talking in sentences (before she had
only one or two word sentences). We saw incredible results with her
sensitivities- she was able to stand a lot more noise, confusion, etc.
without a meltdown. A few months later we did 20 more sessions, two a day
for 10 days straight. This time, we saw more lessening of the sensory
problems. She went from a child who could not stand to have her hands
touched, to a little girl who wanted her nails painted!  We later did 10
sessions, and saw no gains- I would not recommend doing only 10 at a time.
We did 20 more later and saw more decrease in spasticity and more cognitive
gains. Before we ever started treatments, I checked with our pediatrician
about possible side effects. He assured me that HBOT is 100% safe- he also
is a non believer in it, but can't deny the benefits we have seen from it!
********, mom to ********,10, spastic diplegia, hydrocephalus, CVI, optic
nerve atrophy, seizures and autism and *******, 12, nda  from Alberta Canada
===============
Kim,
My daughter is also 16 months old and I have recently finished 40 HBO
treatments.  She had increased tone in her legs and low tone in her trunk. 
Now, the PT has stated Anna Kate has lost the tone in her legs.  She is now
sitting unassisted, will transfer from sitting to crawling and return to a
sitting position.  She is pulling up and  can ambulate slowly behing a push
toy ,however, balance is still a problem in standing upright position.  She
now plays with toys without releasing them, is much more curious, claps
hands, motions bye,bye.
Before HBO, she had to be propped in sitting position, could not hold toys
without releasing them and she appeared sleepy and tired much of the time. 
Has your child mastered true quadrapedic crawling.  Anna Kate crawls all over
the house but it is a "commando type" crawl.  Just curious.  I am amazed at
the results we have seen. 
We are taking a break presently but will return in about a month for more
treatments.   Great to hear from a mom with another 16 month old. 
K******
================
Hi everyone:
I had to post this tonight. Today Michael and I were
at his private OT appointment. I had previously spoken
with his OT about the possiblity of us doing HBO and
she informed me that the kid that she sees ahead of
Michael was currently in Canada receiving treatments.
Well, today was Katie's first day back after 120
treatments. All I can say is that HBO is truly a
miracle. This little girl is 5 years old. Previous to
HBO, she did not walk, talk, communicate or really do
much of anything else. As her mother expressed to me
today, she was pretty much in a vegetative state. She
was full-term, suffered a stroke inutero, has pretty
severe CP.
Well, she is now walking, talking, running, playing,
you name it. I could not believe it! I was so very
glad to see this with my own eyes! And, her mom
attributes all of this to HBO. How is that for a
success story!
April, I do have a question though. Katie is actually
going to do 300 treatments and her mom told me that
she will start her on amino acids when she is done.
Why amino acids?
By the way, I did give her the info on KidPower and
she said that she will be joining any day! Won't she
be a great person to welcome!
*******, mom to ********  2
(right hemi, seizures)
==============
I am a pediatrician who has a four year old daughter with severe cerebral palsy. She has
been receiving physical and occupational therapy from the age of 6 months. At the age
of 3 she could not sit up unsupported. She was able to say about 35 words with
difficulty. She screamed whan she was hungry and would say "miek" when she was
thirsty. A distant relative had suffered a stroke which left him completely blind. He was
able to regain some vision after hyperbaric oxygen therapy. He called me to tell me that
he saw children like mine at the center and encouraged me to take my daughter there. I
procrastinated because I wanted to see if there was any data that showed HBOT would
work. I then finally enrolled my daughter in a study. Within the first week of HBOT
treatments my daughter was able to say "Boos Coos" pertaining to "Blues Clues" a
children tv show and incredibly she did for 45 minutes. For me that was a small miracle.
She had never focused enough before to watch a tv program. With the completion of 80
treatments, she speaks well over 1000 words and can say 4-5 word sentences. She can
indicate her needs and is completely toilet trained. Currently she continues to make
improvments daily. I have noticed that when she is receiving treatments she appears to
be more and more focused and is able to learn much more. I personally believe that    HBOT
has made a huge difference in the quality of her life and ours. I believe in it so much that
I wanted to make this treatment available to other children and families. My new facility
Hudson Valley Hyperbarics in Brewster, NY has the capability to treat all kinds of CP
cases and medical conditions. Please feel free to contact me via email PINAMD@aol.com
to discuss any of your childrens or families conditions.
Sincerely,
Jo Feingold, M.D.
Medical Director Hudson Valley Hyperbarics
==============
Hi.  My son had 39 HBO treatments this summer for a mild case of CP. 
He was spastic diplegic and has been since birth.  He got amazing
results.  We are only 2 months from the treatment and he still
continues to improve.  In fact, I'm wondering how long the
improvements will continue.  If anyone has an answer to this, please
respond.  So anyhow, they say the sooner the better, but at least in
our case, after 13 years there was lots of
improvements..........gait, strength, fine motor, and cognitive.  So,
I'd try the HBO even after 17 years.
Pat
==============
Hello everyone,
My name is Kim, my daughter is Gabriella, (www.gabbyrose.org). Gabby is 5 yrs
old and was injured by the Hep B vaccine she recieved at one day old. She was
diagnoised with static encephalopathy, global developmental delay, cerebral
plasy, PDD, leaky gut, ect, ect, ect. She has had over 120 HBOT. This
wonderful therapy is like a miracle for her. She is now able to drink thru a
straw, eye contact improved, gross motor and fine motor skills improved, she can
get into a standing position by herself, her balance has improved greatly, she
can walk unassisted in the grass and other surfaces, she is climbing on the
furniture and the kitchen table! She is starting to perspire like a normal
child, she initiated and said new words, she is making more sounds and is trying
to sing, dance and jump.
I was wondering if there is a way that you know of to share information about
this fantastic treatment. There are soooo many children and adults who can
benefit from it. Has anyone written editorials for the newspaper or found
another way to really get the word out about this treatment. It seems it is
usually the last thing people try and sometimes parents are so involved with
just managing their children and their circumstances that they don't have the
time to research this option. If we could really 'go public' (major newspaper,
TV, radio) with this, it would make it more available to people and the more
people ask for HBOT, perhaps this will push insurance companies to cover the
'off label' diagnoises that can so benefit from HBOT.
Any ideas?
Thanks,
Kim Waldele
gabbyrose.org
==============
Hello everyone. We are back in Kansas City to do more hyperbarics
at Deister's clinic (lovely people!). I wanted to give you a brief
update on Elena's progress before we begin our next round of
treatment. Due to birth injury, Elena has never been able to
swallow or even close her lips together (she is 4 years old now).
We did our first 40 sessions of HBOT this Oct at Hyperbaric Healing
Institute. After the first week of treatment she was able to close
her lips, so we began feeding therapy at home. Now she swallows a
couple spoonfuls of babyfood every day. She is excited about her
progress (and so am I)! I am looking forward to more changes with
this session of 20 treatments. Then hopefully we will be able to
visit the mobile unit in Eau Claire this spring (we live in St Paul
MN, so that will be much closer). Hyperbaric treatments have been
such a blessing for us!
==============
We just returned home from a doctors appt. We have been seeing the
opthamalogist before and after each 40 sessions of HBO. This is Patrick's 3rd
set of 40 to complete.  Here are his documented results:
1st 40: Cortical blindness upgrade to high use of peripheral vision amd
severe cortical impairments in all central fields of vision
2nd 40: Went from strictly liquid diet to 3 meals aday. Gained 15lbs. grew
8'' in 1 10mths following. End of all gastric issues, removal of GI tube, and
all medication.
3rd set: Eye doctor said "Patrick no longer need to wear his glasses, 60%
improvement since Dec.2000 in farsightedness, normal focusing, responses all
normal in all tests!!!!!!!
Currently we are fundraising to finance the next set of 40 treatments. HBO
has been nothing short of a miracle for Patrick! I hope to hear from others
about their experiences. Jacki mom to Sean 11, Kathleen 8, and Patrick 4 our
vaccine injured angel.
==============