Hyperbaric Oxygenation Therapy in the Treatment of Cerebral Palsy: A Review and Comparison to Currently Accepted Therapies

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1 Hyperbaric Oxygenation Therapy in e Treatment of Cerebral Palsy: A Review and Comparison to Currently Accepted Therapies Carole Sénéchal, Ph.D. Serge Larivée, Ph.D. Engelbert Richard Pierre Marois, M.D. ABSTRACT Hyperbaric oxygenation erapy (HBOT) has shown promise in clinical trials and is sought by many parents of children wi cerebral palsy (CP). There is unusual resistance to expanding e indications for is modality, which is e only treatment available for certain conditions, such as decompression sickness and air embolism, and which is effective in a number of oers related to wound healing. A recent study at showed notable improvements in children wi CP treated wi slightly pressurized air, as well as ose treated wi a standard protocol for HBOT, is invoked to deny effectiveness of HBOT. Political and economic considerations, raer an purely scientific ones, play an important role in is controversy. Furer systematic research is needed, but in e meantime children should not be denied access to HBOT. Hyperbaric oxygenation erapy (HBOT) in e treatment of certain conditions (for example: decompression accidents, gas gangrene, burns) is supported by substantial clinical literature. Some oer conditions (for example: skin or tissue grafts, specific cases of anemia) are also on e accepted indication list but wi scant support from formal clinical trials. Its use in some conditions has proved ineffective, and in oers, especially neurologic, it has been very controversial. In 1994 Harch reported e first Nor American case of HBOT 1 in a child wi cerebral palsy (CP). Around e year 000, some researchers affirmed at, following HBOT, some patients wi CP experienced improvement in motor function,and decreased muscle spasms. Controversy soon developed in e newspapers. Political factors have impeded furer research and e adoption of new 3-8 clinical applications. What is HBOT? In 1999 e drug definition of HBOT was refined and restated as e use of oxygen at greater an atmospheric pressure as a drug to 9 treat basic paophysiologic processes and e associated diseases. Under normal atmospheric pressure at sea level 760 mm Hg, 1 atmosphere absolute or 1 ATA hemoglobin in e blood is already 97% saturated wi oxygen, wi very little capacity for 10 increasing oxygen transport. Oxygen is also dissolved directly in e plasma in a more bioavailable form. According to Henry s Law, e absorption of a gas is directly related to e partial pressure of e gas. About 17 times as much oxygen can be carried in e plasma when e patient breaes 100% oxygen at a pressure of 3 ATA, compared wi breaing room air at sea level (see Table 1). The added pressure can also reduce blood flow to e damaged areas, and 11 hence reducing edema, wiout compromising oxygenation. The pressure must be applied to e entire body. This is accomplished eier in a single-person chamber, usually pressurized wi 100% oxygen, or a multi-place chamber, which is pressurized wi air while patients breae oxygen rough a mask or hood. Multi-place chambers have a reduced fire hazard, but ere is some variability in e concentration of oxygen actually inhaled because of leakage around e mask. This is less true wi e use of a hood. In Canada, in e public system, ere are fewer an a dozen hyperbaric chambers available to treat various medical conditions. Risks of HBOT HBOT, particularly at pressures lower an 1.75 ATA, involves little risk of any major complications. In fact, e risks of HBOT are minimal when technicians obey safety regulations and follow a specific protocol. They include rare decompression accidents. Adverse effects of HBOT on e human body include barotrauma most commonly involving e middle ear, sinuses, or 1 dental restorations. This is reported to occur in % of patients. Most patients are able to prevent ear barotrauma by using simple self-inflation techniques. Reversible myopia may occur during high-pressure treatments. Some patients do not tolerate confinement in a small enclosed space. There are only few absolute contraindications to HBOT (pneumoorax, and treatment wi adriamycin, vincristine, and similar drugs). Conditions such as respiratory infection, chronic sinusitis, epilepsy, optic neuritis, certain lung diseases, and claustrophobia 13 must be carefully evaluated before treatment is auorized. Significant adverse effects are very uncommon: see Table. Rationale for HBOT in CP CP is most often caused by an ischemic/hypoxic injury during e perinatal period. While hypoxia may cause cell dea, ere may sometimes be a zone called e ischemic penumbra, in which brain cells receive just enough oxygen to survive, but not enough to function normally. Since at discovery, many have asked e question: to what extent can HBOT reactivate damaged neurons? It is generally admitted at e cells to which e blood flow is dramatically reduced for 10 minutes or so (less an 10 ml of blood 15 per 100 g of brain tissue per minute) undergo necrosis and form e core of a lesion. Wi less severe hypoxia, some researchers believe at cells can survive for a long time in an idling state, and might be reactivated if blood flow is restored. Those who observed a decrease in spasticity and functional improvements wi HBOT hypoesized at neurons might be viable but inactive much longer 16,17 an previously believed. Table 1. Quantity of Oxygen Dissolved in e Blood Owing to Pressure 37 Pressure Percentage of O inhaled Quantity of O (in ml) dissolved in 100 ml of blood 1 ATA 1% (normal air) ATA 100% 1.7 ATA 100% ATA 100% 5.6 Journal of American Physicians and Surgeons Volume 1 Number 4 Winter

2 Table. Type and Occurrence of Complications and Side Effects of HBOT in 78 Patients 14 Table 3. Studies of HBOT in Children wi Cerebral Palsy Auor Place No. of subjects Machado Sao Paulo, (1989) 16 Brazil No. of treatments Conclusion 0 Decrease in spasticity in 95% of e cases. 6 mons post-treatments: improvement in cognitive functioning or in level of spasticity among 75.6% of e children. Cordoba- Cabeza (1998) 38 Montgomery et al. (1999) Las Tunas, Cuba Montreal, Canada Barrett University of (1999) 39 Texas at Galveston, Texas, USA Packard Cornell (000) 40 University, USA Collet et al. Montreal, (001) 4 Canada 14 0 A satisfactory response was observed among patients treated in e first year following e lesion, wi more significant and more rapidly obtained results. 5 0 The results show an increase in gross motor functions in 3 of e 5 items of e Gross Motor Function Measure (GMFM), an increase in fine motor functions, and a decrease in spasticity Hyperbaric oxygen erapy produced increases in e assessment of gross and fine motor functions, and decreased spasticity among patients wi cerebral palsy Among some children wi moderate to severe cerebral palsy, ere is evidence at HBOT improves motor skills, attention, language, and play. For some children, an improvement in vision was noted. While e treatment is not curative nor miraculous, e changes are often substantial. 111 (1 group tested at 1.3 ATA and 1% O and 1 group tested at 1.75 ATA and 100% O ) 40 The two participating groups improved substantially (wi no difference between e two groups) wi respect to gross motor functions, language, attention, memory, and functional abilities. The auors hypoesized at eier e two treatments were equally effective, or e simple fact of participating in research at allowed communication wi oer children had a positive effect. Waalkes et al. (00) 41 U.S Army 8 80 The assessments compared pre- and post-treatments using several functional measures. HBOT demonstrated an increase in gross motor functions and a decrease in total time of necessary care for e children wi cerebral palsy. Sei and Mukherjee (003) 4 Marois and Vanasse. (006) 43 New-Delhi, India Montreal, Canada Mukherjee New-Delhi, (006) 44 India (15: HBOT + occupational erapy 15: occupational erapy alone) 40 Rate of progress in gross motor functions of e test group (HBOT + occupational erapy) is much more rapid an at of e control group (occupational erapy alone) Significant increases in e GMFM of 3.96% for e entire group of subjects Rate of progress in gross motor functions of e test group (HBOT + erapy) is much more rapid an in e control group (erapy only). Oer mechanisms have also been suggested to explain e sometimes astonishing improvements described bo by researchers and by e parents of children submitted to HBOT. Increased oxygenation is known to enhance neovascularization in wounds, burns, and oer types of lesions; perhaps e same could occur in cerebral lesions. Additionally, increased oxygen might improve e metabolism and function of e remaining 18 normal cells. It has been shown at lowpressure hyperbaric oxygen erapy (LPHBOT) can induce cerebrovascular changes and improve cognitive function in 19 a rat traumatic brain injury (TBI) model. One recent addition to e neovascularization and metabolic hypoeses involves stem cells. One study conducted at e University of Pennsylvania School of 0 Medicine demonstrated at HBOT can cause up to an 8-fold increase in e quantity of stem cells circulating in e human body. Many researchers have demonstrated, using cerebral single photon emission computerized tomography (SPECT scans), increased vascular activity in e brain following treatments in a hyperbaric 1-3 chamber. Empirical Results wi HBOT in CP The first pilot study was conducted by Montgomery et al. and showed at 5 patients wi CP presented a significant increase in eir gross motor functions (5.3%) and fine motor functions, along wi a decrease in spasticity, following 0 sessions of HBOT (95% oxygen at 1.75 ATA for 60 minutes). The video exams of e children before and after HBOT were blindly evaluated and e post-hbot exams were picked as e better exam about 65% of e time. Later studies also demonstrated positive results: see Table 3. 4 Collet et al. conducted a study intended to fill in e gaps of e study by Montgomery et al. Collet et al. studied 111 children: The study group of 57 received 40 sessions of HBOT wi 100% oxygen at 1.75 ATA. The control group of 54 received air at 1.3 ATA, also in a hyperbaric chamber. Bo groups had 60-minute sessions 5 days a week for 8 weeks. Of e 111 children, 107 completed e treatment series, and 101 had a 3-mon follow-up. Gross motor function was assessed using e GMFM (Gross Motor Functional 5 Measure), a standardized tool at is considered e most reliable and objective way to measure gross motor function in children. The children stopped all oer interventions while ey underwent HBOT, so e improvement in GMFM occurred in 110 Journal of American Physicians and Surgeons Volume 1 Number 4 Winter 007

3 Table 4. Comparison of Changes in Gross Motor Functional Measurement (GMFM) Observed among Children wi Cerebral Palsy According to e Type of Intervention. * Law et al. and McGibbon et al. considered only part of e GMFM, e goal area or one of e five dimensions, e E group (running and jumping), respectively. Most children evaluated on e E group have already achieved nearly 100% on oer functions. The degree of improvement on e entire GMFM would probably have been only 0% as great as e reported numerical results suggest. e absence of oer erapies. Bo groups, receiving two different dosages of hyperbaric treatments, improved very significantly following e interventions. The progress persisted after 3 mons. During e mons of treatment e rate of progress was 15 times faster an during e 3 mons follow-up when all usual erapies were reintroduced. No significant differences were noted between e two groups. Scores improved by.9 units in e HBOT group and 3.0 in e pressurized air ( control ) group, P =.544. Oer assessments included performance in daily activities, attention, memory, and language. Bo groups improved significantly in ese areas, wi no significant difference between em. The researchers postulated at eier e two treatments were equally effective or at e mere act of participating in a trial at promoted communication wi oer motivated children and parents had a positive effect. Discussion The introduction of e Internet has brought scientific and medical information to e lay public. While is situation prevents significant discoveries from going unnoticed or from being pushed aside by overly conservative scientists, ere is also e risk of rendering too popular ose treatments for which e proof of effectiveness is clearly insufficient. Not all readers possess e scientific background necessary to evaluate studies properly. All ey feel ey need to know is at it works in certain cases. Thus, wi increasing frequency, patients bring eir doctor material at questions eir previous prescription or suggests e use of a new 6 approach. This tendency might become widespread if e creators of a new approach follow e example of drug companies and launch awareness (marketing) campaigns aimed directly at eir consumers (direct-to-consumer advertising), as proposed by Wicker 7 in 001. The criteria for acceptable proof of effectiveness of HBOT are inconsistent. For example, e use of HBOT was accepted by e 8 Undersea and Hyperbaric Medical Society in 1996 for treating intracranial abscesses on e basis of only 19 cases (13 cases in Germany and six in e United States). On e oer hand, HBOT for CP has not yet been recognized by e UHMS despite e publication or e presentation in international meetings of more an 650 positive cases. Broadening e applications of HBOT since e 1980s in e absence of e unequivocal demonstration of a paophysiologic mechanism, in cases of neurological problems among oers, has led to HBOT being labeled as alternative or experimental. Proponents of evidence-based medicine have been reticent about acknowledging new indications. The 10 studies on e treatment of CP wi HBOT presented in Table 3, even ough some have a small number of participants, have all demonstrated significant and often impressive improvements compared wi what is seen from e majority of known and accepted erapeutic approaches for is condition. In fact, Journal of American Physicians and Surgeons Volume 1 Number 4 Winter

4 depending on e age and e severity of e condition of children wi CP, e rate of progress (see Table 4) measured wi e GMFM can be up to five times higher an e one obtained wi intensive physioerapy (PT) or even after rhizotomy followed by intensive PT. So far, no recognized approaches in e treatment of CP have shown faster or more impressive positive changes in gross motor function. Moreover, most recognized approaches like PT or rhizotomy do not improve cognition or communication. HBOT has an effect on global function of e brain and, besides e very important changes in motor function, e most common improvements reported by more an 80% of e parents are in cognition and language. Lack of rigor in certain research, such as weaknesses in e selection of patients and/or nonstandard protocols, is responsible 9 for e lack of acknowledgement of HBOT, according to Locklear. However, if is argument were e only reason for e neglect of or opposition to HBOT, how could one explain at several approaches (e.g. botulinum toxin) used wi e same population, and which had not been e subject of double-blind research, are noneeless widely accepted and have been paid for by e heal care systems in Canada for more an 10 years? Alough e study was designed in a way meant to minimize possible criticism, e significant results of Collet et al. have been interpreted in such a way at ey refuel e debate instead of contributing to its resolution, even among e auors of is study. The funding organization, e Fonds de Recherche en Santé du Québec (FRSQ), minimized e fact at significant improvement in e state of e participants did indeed take place and attempted to make everyone believe at e treatment at 1.3 ATA was simply a placebo. This misinformation has since been repeated several 4,6 times. We know at pressurized air at 1.3 ATA increases e plasma oxygen concentration by more an %. This effect, delivered by a Gamow bag, saves lives endangered by mountain sickness during high-altitude trips every year. The study by Collet et al. has measured and documented e substantial effect of a small increase in pressure, even wiout supplemental oxygen. Disagreement among researchers is a common occurrence in e scientific world. However, in is case, it appears at Collet 4,6 and e FRSQ wanted to save eir hypoesis instead of submitting to e verdict established by e facts. Indeed, when e results proved positive for e two groups, whereas quite obviously one expected eier insignificant results or a significant difference between e two groups, Collet and e FRSQ preferred to minimize e results of HBOT, instead of acknowledging an effect of e air treatment at 1.3ATA. Controversy about e study began even before publication. The editor requested at ere should not be any reference to e treatment of e control group as inert or placebo raer, it should be called precisely what it was: slightly pressurized air. Following publication, a disagreement among e auors of is study wi regard to e official interpretation of e results spread to several scientific journals. The official conclusion was at HBOT was ineffective for CP, wiout considering e improvements, which were indeed notewory, and even 31 impressive, for bo groups. Misinformation about is research reached its peak when, following its publication in e Lancet, an official communiqué published by FRSQ in 001 changed e title and e conclusion. The title of e published paper was: Hyperbaric Oxygen for Children wi Cerebral Palsy: A Randomised Multicentre Trial, but in e communiqué e FRSQ entitled it: No Advantage of High-Pressure Oxygen for Treating Children wi Cerebral Palsy. Despite e significant results reported in e study, e communiqué stated: hyperbaric oxygen erapy produces no 4 erapeutic effect in children wi cerebral palsy. This communiqué gave rise to anger and indignation among many researchers as well as among e families who participated in e research and who had noted significant progress in eir children. More recently, e U.S. Agency for Healcare Research and Quality (AHRQ) concluded at e presence of pressurized air during e research might have had a beneficial effect on motor functions. It stated: The results of e only truly randomized trial were difficult to interpret because of e use of pressurized room air in e control group. As bo groups improved, e benefit of pressurized air and of HBOT at 1.3 to 1.5 atm should bo be examined in future studies. The auors of e trial ought at e children in bo groups improved because participation in e study provided an opportunity for more stimulating interaction wi eir parents. This is speculative, however, because ere was no evidence to suggest at e parents and eir children had less time togeer, or less stimulating interaction, before e study began...the possibility at pressurized room air had a beneficial effect on motor 3 function should be considered e leading explanation. Despite controversy about e results, e study of Collet et al. paved e way for furer research in HBOT for CP. The question about what did produce e improvements in participants demands an answer. It would certainly be beneficial to repeat e study, is time wi one group wi pressurized 100% oxygen, one group wi pressurized air at 1.3ATA, one group at 7% of O at 1ATA, and one group wi unpressurized air, e last serving as e true control group. Those results might even demonstrate at HBOT as defined 33 by e UHMS in 006 (100% O at a minimum of 1.4 ATA) is not necessary for treating children wi CP if an attenuated treatment, slightly pressurized air (1% O at 1.3 ATA) or even 7% O at 1ATA, can do e job. Until very recently, e Quebecois Government s position was not very favorable toward any additional research on e effects of is treatment on children wi CP. Adopting at position, it aligned itself wi e position adopted by Heal Canada in 006, which recognizes e effectiveness of HBOT in e treatment of certain conditions but formally challenges its effectiveness for CP, by stating: right now, noing has demonstrated e usefulness of 34 is treatment. Nevereless, a law enacted in March 005 auorizes e Department of Revenue of Quebec to grant tax credits to Quebecois 35 families to treat children wi CP wi HBOT. Moreover, in May 006, e Department of Heal of Quebec entrusted to e Agence d Évaluation des Technologies et des Modes d Intervention en Santé (AETMIS) e mandate to examine e effectiveness of 36 HBOT in CP. The AETMIS report concluded ere was enough evidence to recommend furer investigation on e effect of HBOT in CP. A number of questions need to be addressed, including e effect of participation in an organized trial; e optimal or minimum necessary pressure and oxygen concentration; and e number and frequency of treatments needed to produce a maximal result. Conclusions Previous studies of HBOT in CP have shown notewory favorable results, but to produce conclusive evidence, additional, more systematic trials are needed. Much is at stake. Improvement in e function, independence, and comfort of persons wi a severely disabling neurologic condition could lead to significant improvements in heal and quality of life as well as to significant cost savings in e long term. While oer treatment modalities are paid for by government programs, parents must bear e cost of HBOT as e controversies continue. In e meantime, given e very low risk of adverse effects and e promising results, children should be allowed access to HBOT. 11 Journal of American Physicians and Surgeons Volume 1 Number 4 Winter 007

5 Carole Sénéchal, Ph.D., is a professor in e Département de psychoéducation, Université du Québec à Trois-Rivières; Serge Larivée, Ph.D., is a professor in e École de psychoéducation, Université de Montréal; Engelbert Richard is wi A&C Produits Chimiques Américains Ltée; Pierre Marois, M.D., F.R.C.P.(c) is a pediatric physiatrist, Department of Physical Medicine and Rehabilitation, Ste-Justine University Hospital, 3175 Rue de la Côte Ste-Caerine, Montréal, Quebec, Canada H3T 1C5. REFERENCES 1 Harch PG, Gottlieb SF, Van Meter KW, Staab P. HMPAO SPECT brain imaging and low pressure HBOT in e diagnosis and treatment of chronic traumatic, ischemic, hypoxic and anoxic encephalopaies. Undersea Hyperb Med 1995;1(Suppl):. Montgomery D, Goldberg J, Amar M, et al. Effects of hyperbaric oxygen erapy on children wi spastic diplegic cerebral palsy: a pilot project. Undersea Hyperb Med 1999;6: Baril D. L oxygénoérapie améliore la récupération à la suite d un AVC. Forum 003;38(18):7. 4 Paré I. Le débat sur le traitement de la paralysie cérébrale reprend de plus belle. Le Devoir, Feb 4-5, 001, pa5. 5 Canadian Press. Une autre étude remet en cause l efficacité des chambres hyperbares. La Presse, Sep 4, 000, pa9. 6 Roy A. Traitement hyperbare et paralysie cérébrale. Les parents payent parce qu ils ne peuvent plus attendre. Le soleil, Jan 3, 005a, pa6. 7 Roy A. Traitement hyperbare et paralysie cérébrale. Un film au lieu d une poursuite. Le soleil, Jan 3, 005b, pa1. 8 Roy A. Traitement hyperbare et paralysie cérébrale. Pas de miracle, mais une amélioration certaine. Le soleil, Jan 3, 005c, pa6. 9 Harch PG, Neubauer RA. Hyperbaric oxygen erapy in global ischemia, rd anoxia, and coma. In: Jain KK, ed. Textbook of Hyperbaric Medicine, 3 ed. Seattle, Wash.: Hogrefe and Huber; Bakker DJ. Hyperbaric oxygen erapy: past, present and future indications. In: Erdmann W, Bruley DF, eds. Oxygen Transport to Tissue XI. New York, N.Y.: Plenum Press; 199: Hardy P. Investigation neuropsychologique des effets de l oxygénoérapie hyperbare sur divers désordres neurologiques. Unpublished esis. University of Montreal, Montreal; Undersea and Hyperbaric Medical Society. Hyperbaric Oxygen Therapy Committee Report. Kensington, Md.: UHMS; Sacré-Cœur Hospital; 006. Available at: hscm/hyperbare.html. Accessed Oct 1, Plafki C, Peters P, Almeling M, Welslau W, Busch R. Complications and side effects of hyperbaric oxygen erapy. Aviat Space Environ Med 000;71: Astrup J, Siesjo BK, Symon L. Thresholds of cerebral ischemia e ischemic penumbra. Stroke 1981;1: Machado JJ. Clinically observed reduction of spasticity in patients wi neurological diseases and in children wi cerebral palsy from hyperbaric oxygen erapy. Presented at e American College of Hyperbaric Medicine, Orlando, Fla.; Neubauer RA, Gottlieb SF, Kagan RL. Enhancing idling neurons. Lancet 1990; 335: Harch PG, Kriedt CL, Weisend MP, Van Meter KW, Suerland RJ. Low pressure hyperbaric oxygen erapy induces cerebrovascular changes and improves cognitive and motor function in a rat traumatic brain injury model. [Abstract]. Undersea Hyperb Med 1996;3(Suppl): Harch PG, Kriedt CL, Weisend MP, Van Meter KW, Suerland RJ. Low pressure hyperbaric oxygen erapy (LPHBOT) induces cerebrovascular changes and improves cognitive and motor function in a rat traumatic brain injury model. [Abstract]. Undersea Hyperb Med 001;8(Suppl): Thom SR, Bhopale VM, Velazquez OC, et al. Stem cell mobilization by hyperbaric oxygen. Am J Physiol Heart Circ Physiol 006;90:H Harch PG, Van Meter KW, Gottlieb SF, Staab P. The effect of HBOT tailing treatment on neurological residual and SPECT brain images in type II (cerebral) DCI/CAGE. Undersea Hyperb Med 1994;1(Suppl):-3. Neubauer RA. Hyperbaric oxygenation for cerebral palsy. Lancet 001;357:05. Auor reply: Neubauer V, Neubauer RA, Harch PG. HBO in e management of cerebral palsy. In: Jain KK, ed. Textbook of Hyperbaric Medicine, 4 ed. Seattle, Wash.: Hogrefe & Huber; Collet JP, Vanasse M, Marois P, et al. Hyperbaric oxygen for children wi cerebral palsy: a randomised multicentre trial. Lancet 001; 357: Nordmark E, Jarnlo GB, Hagglund G. Comparison of e Gross Motor Function Measure and Paediatric Evaluation of Disability Inventory in assessing motor function in children undergoing selective dorsal rhizotomy. Dev Med Child Neurol 000;4: Lanoix-Nadeau C. In pursuit of hyperbaric oxygen erapy. Hyperbaric Medicine Today 000;1(3): Wicker RR. Hyperbaric oxygen erapy and direct-to-consumer (DTC) advertising: how we may benefit. Hyperbaric Medicine Today 001;1(6): Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy Committee Report. Kensington, Md.: UHMS; Locklear K. Hyperbaric oxygen erapy: its use and appropriateness. Department of Heal and Human Services, Office of Inspector General. Hyperbaric Medicine Today 000;1(4): Austin D. Gamow bag for acute mountain sickness. Lancet 1998;351: Marois P, Vanasse M. Hyperbaric oxygen erapy and cerebral palsy. Dev Med Child Neurol 003;45: Auor reply : Agency for Healcare Research and Quality (AHRQ). Systems to rate e streng of scientific evidence. Evidence Report/Technology Assessment no.47. Rockville, Md.: AHRQ; 003. Available at: clinic/epcsums/hypoxsum.htm. Accessed Oct 1, 007. Undersea and Hyperbaric Medical Society. Indications for Hyperbaric Oxygen Therapy; 006. Available at: indications.htm. Accessed Oct 1, 007. Heal Canada. Oxygénoérapie; 006. Available at: ca/iyh-vsv/alt_formats/cmcd-dcmc/pdf/hyper_f.pdf. Accessed Oct 1, 007. Pineau G, Maqadem, K. Place de l oxygénoérapie hyperbare dans la prise en charge de la paralysie cérébrale. Montréal, Canada: AETMIS; 007. Renseignements additionnels sur les mesures du budget. Budget Québec: Gouvernement du Québec; 005. Camporesi EM. Psychological Principles of Hyperbaric and Oxygenation. A Handbook of Hyperbaric Medicine. New York, N.Y.: Springer Verlag; 1996: Cordoba-Cabeza T, Perez-Fonseca R, Morales-Vargas D, Lopez A. Oxigenación hiperbárica y restauración neurológica en niños con daño cerebral orgánico. Rev Neurol 1998;7: Barret K. Pediatric cerebral palsy treated by 1.5ATAhyperbaric oxygen a pilot study. Presented at e First Annual Symposium: HBO and e Recoverable Brain, Fort Lauderdale, Fla., Packard M. Hyperbaric oxygen erapy and cerebral palsy. Presented at e University of Graz, November 000. Waalkes P, Fitzpatrick DT, Stankus S, Topolski R. Adjunctive HBO treatment of children wi cerebral anoxic injury. Army Medical Dept J 00;(April-June):13-1. Sei A, Mukherjee A. To see e efficacy of hyperbaric oxygen erapy in gross motor abilities of cerebral palsy children of -5 years, given initially as an adjunct to occupational erapy. Indian J Occup Ther 003; 35(1):7-11. Marois P, Vanasse, M. HBOT in e treatment of cerebral palsy: a retrospective study of 10 cases 5 years. Presented at 5 Annual Symposium: HBO and e Recoverable Brain, Fort Lauderdale, Fla., July 006. Mukherjee, A. Udaan HBOT-based multimode erapy for cerebral palsy. Presented at 5 Annual Symposium: HBO and e Recoverable Brain, Fort Lauderdale, Fla., July 006. Russell DJ, Rosenbaum PL, Cadman DT, et al. The Gross Motor Function Measure: a means to evaluate e effects of physical erapy. Dev Med Child Neurol 1989;31: Trahan J, Malouin F. Changes in e Gross Motor Function Measure in children wi different types of cerebral palsy: an eight-mon follow-up study. Pediatr Phys Ther 1999;11:1-17. Hays RM, McLaughlin JF, Bjornson KF, et al. Electrophysiological monitoring during selective dorsal rhizotomy, and spasticity and GMFM performance. Dev Med Child Neurol 1998;40: Wright FV, Sheil EM, Drake JM, Wedge JH, Naumann S. Evaluation of selective dorsal rhizotomy for e reduction of spasticity in cerebral palsy: a randomized controlled trial. Dev Med Child Neurol 1998;40: McLaughlin JF, Bjornson KF, Astley SJ, et al. The role of selective dorsal rhizotomy in cerebral palsy: a critical evaluation of a prospective clinical series. Dev Med Child Neurol 1994;36: Steinbok P, Reiner A, Kestle JR. Therapeutic electrical stimulation following selective posterior rhizotomy in children wi spastic diplegic cerebral palsy: a randomized clinical trial. Dev Med Child Neurol 1997;39: McLaughlin JF, Bjornson KF, Astley SJ, et al. Selective dorsal rhizotomy: efficacy and safety in an investigator-masked randomized clinical trial. Dev Med Child Neurol 1998;40:0-3. Damiano DL, Abel MF. Functional outcomes of streng training in spastic cerebral palsy. Arch Phys Med Rehabil 1998;79: Almeida GL, Campbell SK, Girolami GL, Penn RD, Corcos DM. Multidimensional assessment of motor function in a child wi cerebral palsy following intraecal administration of baclofen. Phys Ther 1997;77: Law M, Russell D, Pollock N, et al. A comparison of intensive neurodevelopmental erapy plus casting and a regular occupational erapy program for children wi cerebral palsy. Dev Med Child Neurol 1997;39: McGibbon NH, Andrade CK, Widener G, Cintas HL. Effect of an equinemovement erapy program on gait, energy expenditure and motor function in children wi spastic cerebral palsy: a pilot study. Dev Med Child Neurol 1998;40: Knox V, Evans AL. Evaluation of e functional effects of a course of Boba erapy in children wi cerebral palsy: a preliminary study. Dev Med Child Neurol 00;44: Tsorlakis N, Evaggelinou C, Grouios G, Tsorbatzoudis C. Effect of intensive neurodevelopmental treatment in gross motor function of children wi cerebral palsy. Dev Med Child Neurol 004;46: Sterba JA, Rogers BT, France AP, Vokes DA. Horseback riding in children wi cerebral palsy: effect on gross motor function. Dev Med Child Neurol 00;44:1-8. Journal of American Physicians and Surgeons Volume 1 Number 4 Winter

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