HBOT and Cerebral Palsy

Cerebral Palsy and HBO Therapy (from Hbot today)

More than 500,000 Americans have cerebral palsy (CP). There are more than 4,500 new cases of CP each year. The term cerebral palsy is not a diagnosis; it is a loose descriptive term that is used to describe a group of chronic disorders—specifically, motor disorders—which impair the control of movement. These disorders usually appear in the first few years of life.

Cerebral refers to the brain's two hemispheres, or halves that contain the higher nerve centers. Palsy refers to any condition marked by tremor or any disorder that impairs control of body movement. CP is not describing disorders in the muscles or in the nerves. The impairment stems from damage to the motor areas of the brain, which in turn cause the brain to poorly control movement of the body's muscles.

What is the Cause of CP?

Although it was once believed that birth complications were the most frequent cause of cerebral palsy, we now know that such complications account for just a fraction of the cases. A study by the Federal Government's National Institute of Neurological Disorders and Stroke (NINDS) in the 1980s confirmed that birth complications accounted for probably less than 10 percent of the total cases of CP. This drastically altered medical theories about cerebral palsy. The NINDS study also confirmed that in most cases, no direct cause for CP could be found.

Types of Cerebral Palsy

There are four broad categories of cerebral palsy: spastic, athetoid, ataxic, and mixed forms that are defined by the type of movement disturbance disorder in each case. Spastic cerebral palsy affects 70 to 80 percent of patients. Patients who suffer from spastic cerebral palsy have muscles that are stiffly and permanently contracted. Doctors often describe the type of spastic cerebral palsy a patient has based on which limbs are affected.

Medical Disorders

There are other medical disorders associated with cerebral palsy. These include:
Seizures or epilepsy. Up to half of all children with CP experience one form of seizure or another.

Mental impairment. Although about one-third of children with CP are not intellectually impaired, one-third are mildly impaired, and the remaining third are moderately to severely impaired.

Vision and hearing problems. A large number of children with CP have a condition called "strabismus," characterized by the eyes failing to properly align because of differences in the left and right eye muscles.

Growth problems. A syndrome called failure to thrive is common in children with moderate to severe cerebral palsy. Failure to thrive is a term that is used to describe growth and development that does not meet realistic expectations in infants and children.

Sensation and perception problems. The ability to feel certain sensations, such as touch and pain, can be impaired in some children with CP. These children may also have stereognosia, a condition characterized by difficulty identifying objects using the sense of touch.

Hyperbaric Oxygen (HBO) Therapy

HBO therapy is a medical treatment that uses the administration of 100 percent oxygen at controlled pressure (greater than sea level) for a prescribed amount of time—usually 60 to 90 minutes. HBO therapy is commonly used to treat conditions such as burns and difficult healing wounds. HBO therapy facilitates healing in these conditions by increasing the amount of oxygen in the blood by up to 2000 percent, depending on the treatment depth. This in turn dramatically increases the amount of oxygen at the cellular level.

In the case of cerebral palsy in children, HBO therapy is administered at 1.5 ATA or equivalent to a depth of 16.5 feet below sea level. Some research has been completed using treatment depths up to 1.75 ATA, or 25 feet below sea level, with positive results. Each treatment lasts one hour and one or two treatments are prescribed each day, five or six days per week. The total number of treatments given in each case varies. It is common to administer 40 treatments in the first phase of treatment. The question of further HBO therapy is then resolved by the medical team involved in each case and is dependent upon a number of factors. However, many believe that if improvement is observed in the first phase of treatment, then a break of one to four weeks should be taken, followed by another 40 HBO treatments.

At the Chico Hyperbaric Center we use a multiplace chamber, which allows a parent to be in the chamber with their child during treatment. Also, no patient at the Chico Hyperbaric Center undergoes treatment without a health care professional in attendance during treatment.

Promising Therapy

Why does HBO therapy show promise in helping cerebral palsy patients? First, let's confirm some previously mentioned facts. Cerebral palsy is the result of damage to motor areas in the brain. This in turn disrupts the brain's ability to properly control the movement of the body's muscles.

What causes this damage?

A National Institute of Neurological Disorders and Stroke (NINDS) study found that in most cases of CP, no direct cause for the damage could be found. In other words, cerebral palsy is a result of the brain not properly communicating with the muscles because the brain has been damaged for one reason or another. Documentation now exists that clearly shows that HBO therapy can dramatically improve some CP symptoms. For example, a study in Brazil1 revealed a 50 percent reduction in spasticity of 94 percent (218 patients) of the patients involved in the study. Improvements have also been seen with vision, hearing, and speech. However, one should understand that improvement, if any, will vary from patient to patient. (Also see the CP section of our Patient's Feedback page for one parent's view of how HBO therapy at the Chico Hyperbaric Center positively affected her child.)

Dormant Areas

Back to our question, "Why does HBO therapy show promise in helping cerebral palsy patients?" In order to answer this question we need to look at one of the terms that we use to describe the type of brain injury involved in cerebral palsy. The term is traumatic brain injury.Traumatic brain injury (TBI) is a condition in which certain nerve cells in the brain may be permanently destroyed. Conditions such as stroke and cerebral palsy are forms of TBI. It is important to note that although some of the brain may be permanently damaged when TBI occurs, a much larger area surrounding the permanently damaged area may also be affected. This larger area may be in a dormant state because the amount of oxygen it receives has been reduced due to a decrease in blood flow. Swelling and a change in cell physiology can cause reduced blood flow.

Reduced blood flow—and the resulting decrease in oxygen levels at the cellular level—as well as the swelling of brain tissue are of particular importance when attempting to understand traumatic brain injury and cerebral palsy in children. This is because some researchers believe that the lack of oxygen and swelling of brain tissue plays a part in the inability of the myelin sheaths to develop.

Myelination

Myelin sheaths are coverings that protect nerve fibers in the brain. These nerve fibers connect the brain to the spinal cord and they play an important role in impulse transmission. The process of myelination—that is, the action of the delicate myelin sheath cells as they envelop the brain's nerve fibers—begins a month prior to birth and continues until about two years of age. If myelination does not properly occur, the nerve fibers are left exposed and they slowly deteriorate. This disrupts communication between the controlling nerve cells in the brain and the muscles. The result may be spasticity. Given the presence of just a small amount of oxygen, the cells in the dormant area may remain in this suspended animation state for many years. The dormant area is often referred to as "not dead but sleeping." This is where HBO therapy shows such promise. It is believed that the high oxygen levels that are attained in the body's cells during HBO therapy cause a physiological change to the cells of this dormant area—effectively waking them up—thus, increasing the capacity for recovery. It is also believed that HBO therapy reduces swelling in the brain by constricting blood vessels, and provides an ideal internal environment for the growth of new brain tissue.It should be remembered that HBO therapy is not a cure, but a method of ensuring that the most complete recovery possible takes place. The degree of improvement will vary from patient to patient because the amount and type of damage to the brain varies with each patient.

The SPECT Scan

Modern technology has been a positive factor in the treatment of cerebral palsy and other forms of traumatic brain injury. Specifically, SPECT imaging, or what is commonly termed the SPECT scan, is helping to identify those parts of the brain that are in a dormant state due to a lack of oxygen. As Dr. Philip James of the Wolfson Hyperbaric Medicine Unit at the University of Dundee in Scotland has stated, "Loss of function in the brain can be either due to tissue swelling, which is reversible, or tissue destruction, which is not."2 When we combine what Dr. James said with what the SPECT scan can do, it is clear that the SPECT scan can help us identify those parts of the brain that stand a chance of being revived.

SPECT stands for Single Photon Emission Computed Tomography. The SPECT scan can give a clear picture of which parts of the brain are awake and working, which parts are dormant and sleeping, and which parts are lifeless and permanently damaged. This is of particular significance when considering HBO therapy because, to be blunt, the SPECT scan has the ability to indicate if HBO therapy is working or not by monitoring the change in brain tissue blood flow.

Let's Sum Up

Some brain cells become dormant due to a lack of oxygen, which can be caused by reduced blood flow. Swelling can cause reduced blood flow. HBO therapy has been shown to reduce the swelling of brain tissue by constricting blood vessels. Also, HBO therapy dramatically increases the amount of oxygen at the cellular level, which, it is believed, may revive dormant, oxygen starved areas of the brain. The ability to perform a SPECT scan before and after a course of HBO therapy can help identify those parts of the brain affected by the therapy. The SPECT scan will identify those areas of the brain that have reacted in a positive manner to an increase in oxygen, indicating the potential for recovery.

Timing Is Important

Obviously, the earlier that HBO therapy can be administered, the better the opportunity for recovery. However, HBO therapy has been shown to resolve tissue swelling even after the lapse of years. It is hoped that HBO therapy will also help revive the secondary, dormant areas of the brain that are not permanently damaged. This appears to be true for stroke patients and there are encouraging results indicating that this may also be true for cerebral palsy patients as well.

Risks?

HBO therapy is a medical procedure, and like any other medical procedure there can be risks. However, when HBO therapy is administered by trained health care individuals these risks are minimal. (As with any medical procedure, the evaluation and understanding of the current health status of the patient is of prime importance.) Minor ear discomfort is the most common complaint related to HBO therapy. This may present a greater concern with young children who cannot verbalize this discomfort. It is helpful to remember that the initial stage of each HBO treatment session is similar to sitting in an aircraft while it descends. Like the airline passenger, the patient's ears have to adjust to a change in air pressure. The hyperbaric health care professional works with the patient or parent and teaches them various techniques on how to equalize pressure in the ears, such as swallowing.If one cannot equalize the pressure in the ears, damage can occur to the eardrum. However, this is very rare. Some individuals who experience discomfort with their ears may require a procedure called a Myringotomy, or what is commonly called placing tubes in the ears. An ear, nose and throat specialist usually performs this outpatient procedure right in the doctor's office.Other complications can occur if a patient has lung abnormalities such as emphysema. However, with proper evaluation prior to HBO treatment any concerns can be eliminated. There is no evidence that other potential problems associated with much deeper depths are a concern at the relatively low pressures attained during HBO therapy for cerebral palsy patients (1.5 ATA or equivalent to a depth of 16.5 feet below sea level).

Research

The benefits of treating cerebral palsy with HBO therapy appear to be very positive. Several research studies have been completed, including studies at the University of Texas Medical Center (UTMC) and McGill University in Montreal, Canada. Some controversy exists with respect to the McGill study as results indicated the placebo group, treated with ambient air at 1.3 ATA, showed improvement similar to the group treated with HBO. Most experts agree that the methodology for evaluation in the McGill study was not optimal. Other research continues and more recently Dr. Maurine Packard of NY Presbyterian Hospital studied the effects of HBO in children ages 1-5 with moderate to severe CP. These studies and additional research will add to our knowledge and understanding of CP and HBO therapy. For the complete text of these studies, and others, please visit the Research Studies section of this site or click on the following link: http://hbotoday.com/treatment/clinical/researchstudies.

References:

Jose Jorge Machado, Clinically Observed Reduction of Spasticity in Patients with Neurological Diseases and in Children with Cerebral Palsy from Hyperbaric Oxygen Therapy. Machado is Neurological Advisor of "Centro Brasileiro de Medicina Hyperbarica" - Rua Bento de Andrade, 70, Sao Paulo, Brazil.

James, Phillip. Hyperbaric Oxygen Therapy for Cerebral Palsy Children.

Paleg, Ginny. Hyperbaric Oxygen Therapy for Individuals with Neurological Dysfunction.

Ocean Hyperbaric Center. New Hope for the Neurologic Damaged Child, Cerebral Palsy, Anoxic Ischemic Encephalopathy and Traumatic Brain Injury

Southern Medical Journal, September 1994, Vol. 87, No. 9; An Investigation of the Treatment of Cerebral Palsy Children with Hyperbaric Oxygenation Using Spect Imaging.

National Foundation for Brain Research, Cerebral Palsy, 1996

Friday, May 7, 2010