Miracle or mistake?

According to a story on a CBS (US) television station, a controversial therapy may yield miraculous results. As a reporter for the CBS, Dr. Holly Phillips covered the use of hyperbaric oxgen chambers as a treatment for Autism. She told the story of a family who sought treatment from a New Jersey (US) doctor; the doctor, James A. Neubrander, MD, treated the child with vitamins and oxygen delivered at high pressure. Despite substantial reasons not to cover it, and Dr. Phillips notes them, the popular press continues to report stories such as the one in my lead.

People who follow follow developments in the treatment of Autism have heard about a therapy in which the individual with Autism spends time in a chamber filled with oxygen at a higher-than-normal pressure. “Hyperbaric Oxegen Therapy” (HBOT for short). Originally developed to treat excessive nitrogen in the blood often associated with coming to the surface quickly while deep-sea diving, HBOT has been tested with many other conditions more recently. Although there are modestly encouraging results for some conditions (e.g., idiopathic sudden sensorineural hearing loss) some other conditions (e.g., cerebral palsy) have not responded to HBOT. Still, as happens after spring rain falling on earth covering a rotting set of roots, clinics offering HBOT are appearing like mushrooms.

The Undersea and Hyperbaric Medical Society (UHMS), which describes itself as “the primary source of information for diving and hyperbaric medicine physiology worldwide,” approves of the use of HBOT for air or gas embolism, carbon monoxide poisoning (including carbon monoxide poisoning complicated by cyanide poisoning), clostridal myositis and myonecrosis (gas gangrene), crush injury, compartment syndrome, and other acute traumatic ischemias, decompression sickness, enhancement of healing in selected problem wounds, exceptional blood loss, intracranial abscess, necrotizing soft tissue infections, refractory osteomyelitis, delayed radiation injury, compromised skin grafts and flaps, and thermal burns.

Dr. Neubrander, who received an MD from Loma Linda University (link to his vita) and who routinely prescribes vitamin therapy as well as HBOT and advertises chelation therapy, points to his descriptions of parents’ reports about improvements in their children following HBOT as evidence of the effectiveness of HBOT (link). Although he calls for research on the therapy, he offers no scientific data that it causes improved language or behavior. There are no control groups, let alone randomly assigned controls. There are no control conditions. There are no procedures to ensure that the patients, assessors, and administrators of the therapy are naive about the conditions (single-, double-, or triple-blind). There are no data about the technical trustworthiness of the measures of language or behavior. I did not find Dr. Neubrander’s name among those who are diplomates of the UHMS.

There is a report by M. Markley from a firm advocating HBOT, but it has very little to recommend it. It’s a pre-post study with no controls and very little information about the measures. A very widely cited source among the advocates is a position paper by David Rossignol (2006); he presented the rationale for using HBOT, but stated the support as a hypothesis, not proof.

In 2006 M. H. Bennett reported the results of an integrative review of the literature on HBOT; his thesis, entitled “The evidence basis of diving and hyperbaric medicine – a synthesis of the high level clinical evidence with meta-analysis,” reported no evidence of the effects of HBOT on Autism. Link to his publicly accessible report. There is even some concern about whether HBOT might cause harm. For example, although he did not review the literature on them, Professor Scott Lilienfeld (2007) expressly noted HBOT and chelation in his review of potentially harmful treatments.
Fortunately, some sensibly cautious folks around the Internet have been suggesting restraint in adopting HBOT for some time now. See, for examples, Orac’s clever coverage over on Respectful Insolence, Chris Tregenza’s treatment over on Myomancy, Harold Doherty’s note about a study from Facing Autism in New Brunswick, and Peter Lipson’s debunking over at Science Based Medicine.

Link to Dr. Phillips’ report, where one can watch a video as well as read the coverage.

Lilienfeld, S. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.
Rossignol, D. A. (2007). Hyperbaric oxygen therapy might improve certain pathophysiological findings in autism. Medical Hypotheses, 68, 1208-1227.

2 Responses to “Miracle or mistake?”

  • John,

    You make some very good points above. As a member of the UHMS committee that tries to make rational, evidence-based decisions about identifying those indications for which HBOT might be routinely indicated, I have given these issues considerable thought over the years.

    I am not sure how useful it will be to others, but one of the guiding principles for me is the concept of ‘prevalence/evidence linking’. By this I mean that for a relatively common condition (e.g. autism) we should expect a high level of clinical evidence before accepting the wisdom of applying the therapy widely. On the other hand, our requirement for high level evidence may need to be relaxed when considering the treatment of very uncommon conditions (e.g. gas gangrene). There are simply not enough cases for us to consider undertaking a large randomised controlled trial and we will have to make our choices on lower levels of evidence.

    The UHMS list is not perfect in my personal opinion, but it is the best, most rationally examined such list available and is under constant examination such that conditions may be added or removed as the evidence accumulates.

    Mike Bennett

  • Dr. Bennett, thanks very much for the comment. I’m glad to have the affirmation of my analysis that you’ve provided here.

    Also, I’m intrigued by the the idea of a ratio between prevalence and evidence. Thanks for alerting me to it.


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