Dr Graeme Kay explains the medical evidence behind what we can treat.
Doctor Graeme Kay is the director of a hyperbaric medicine facility. He has extensive post graduate medical experience and specialist credentials in primary care as well as diving and hyperbaric medicine. This makes him one of the most qualified and respected doctors for Hyperbaric Medicine in the region.
On a daily basis I am asked by patients who feel let down by the traditional medical establishment to treat their conditions. I almost never treat these people. I say almost because there is a role for research into treating conditions with novel therapies, but only under the guise of a formally structured research program with ethical consideration and approval.
The current flavours of condition outside my realm of accepted practice include autism, cerebral palsy, acquired brain injury, chronic fatigue syndrome and Lyme disease.
I imagine that people with these conditions seek my facility because they have exhausted what they feel traditional medicine can give them.
Unfortunately there is no shortage of unscrupulous traders out there, purveying their modern miracle magical cure.
It is possible to some degree to trace back in the literature when the current deviation from accepted practice occurred.
In 2001 a randomised sham-controlled study of 111 children with Cerebral palsy (CP) who received either 40 HBOT treatments at 1.75 ATA, or 40 air sessions at 1.3 ATA (Sham) was published.1 Both groups were found to improve in their outcome measures but with no difference between the groups. This was ascribed to a participation effect by the authors, a finding that was supported by an independent scientific advisory committee.2
There was a group within the hyperbaric medicine community, which is not supported by the community at large, that interpreted this result as an active effect of pressure, even as low as 1.3ATA which is the equivalent of 3m Salt water of pressure or 30kPa. A second sham controlled study was published in 2012 with 49 children with CP enrolled and randomised to receive 40 HBOT treatments at 1.5 ATA or 40 exposures of 1.5ATA breathing a 14% fraction of oxygen (resulting in an equivalent inspired fraction of 21%, thus eliminating the possibility of in increased inspired PO2 being attributable to any effect). Again this study found significant improvement in carer reported disability inventory but with no difference between either group.3
Similar studies for the use of HBOT for mild traumatic brain injury have been conducted. In all these studies there were reported improvements beyond that expected, but no discernible difference between treatment groups. Again a small proportion of the hyperbaric medicine community have attributed this result to a physiological effect from exposure to increased pressure, whilst the majority of the community considers the results to be that of a participation effect. 4,5
As such, the majority of hyperbaric physicians across the globe are of the opinion that delivering ‘mild hyperbaric’ treatments of 1.3ATA breathing air, concentrated oxygen or pure oxygen, has no actual physiological effect. It could be argued that at best, it is a misguided poor interpretation of the data currently available, at worst a wilful and duplicitous disregard for scientific method, being used as rationale for requesting payment for a treatment that is proven to have no benefit.
As credible hyperbaric medicine practice currently exists in Australia, a hyperbaric medicine facility must be a comprehensive hospital based hyperbaric unit with ability to treat all presentations up to and including ICU level of care, and rostered staff including a doctor with extensive training in diving and hyperbaric medicine and nursing staff also suitably trained available 24/7 in order to collect Medicare rebate and in turn access private health funds.6
As such, asking the following questions prior to undergoing hyperbaric treatments may help to sort the woo from fact:
- Is the condition being treated one of the 14 conditions the UHMS recognises as benefiting from hyperbaric treatments?7
- If not, does a logical and mechanism exist that has been supported by research in human, animal or in vitro models?
- What sort of treatment is being provided? If it is less than 2ATA of pressure, and if less than 100% oxygen is being supplied, then there is no evidence that treatment has any efficacy.
- Is the treatment being provided by a trained doctor and nursing staff? If not, the facility does not comply to the Australian standard 4774.2 and is not eligible for Medicare subsidy.
- Am I being asked to pay out of pocket for treatment? The majority of Medicare compliant facilities exists as part of public hospitals and require no out of pocket payments. The private facilities that are Medicare Benefits Schedule and AS 4774.2 compliant access Medicare and private health funds for payment for most but not all 14 UHMS recommendations. As such there is usually no out of pocket expense other than any hospital admission co-pay that the patient has negotiated with their fund on joining plus an assessment fee.
By reviewing the above queries, you should be able to satisfy yourself that the services being provided are being applied in an evidence based manner, by trained healthcare staff operating ethically as bound by AHPRA, in a facility that is compliant to the appropriate industry standards to ensure treatments are provided as safely as possible.
- Collett J-P, Vanasse M, Marois P, Amar M, Goldberg J, Lambert J, et al. Hyperbaric oxygen for children with cerebral pals: a randomised multicentre trial. Lancet 2001;357:582-6
- Scientific Advisory Committee. Report Hyperbaric oxygen therapy for children with cerebral palsy: a multicentre randomised clinical trial. Quebec, Canada: Fonds dela recherche en santa du Quebec; 2000
- Lacey DJ, Stolfi A, pilat LE. Effects of hyperbaric oxygen on motor function in children with cerebral palsy. Ann Neurol. 2012;72:695-703
- Harch PG, Andrews SR, Fogarty EF, Amen D, Pessullo JC, Lucarini J, et al. A phase 1 study of low pressure hyperbaric oxygen therapy for blast induced post concussion syndrome and post traumatic stress disorder. J Neurotrauma. 2012;29:168-85
- Weaver LK, Cifu D, Hart B, Wolf G, Miller RS. Hyperbaric oxygen for post concussion syndrome: design of department of Defense clinical trials. Undersea hyperb Med 2012;39:807-14.