Hyperbaric oxygen in the treatment of childhood autism: a randomised controlled trial

24 Oct

Hyperbaric Oxygen therapy (HBOT) has risen in recent years as an “alternative” therapy for many conditions, autism included. The logic behind HBOT is rather fuzzy. For example, there was some discussion of using HBOT to reduce oxidative stress a few years back. How increasing oxygen in the body would decrease oxidative stress was not clear. Some other discussions focused on oxygen perfusion. Basically, some studies have shown that some areas of the brain may be getting less oxygen in autistics than in non-autistics. The idea was that increasing the oxygen to those areas might result in some improvement in some measure or another.

This begs the question: are there areas of higher perfusion (hyperperfusion) in the brains of autistics? Seems an important question to pose when proposing increasing perfusion. But one can not find the term “hyperperfusion” in this review promoting HBOT and autism, for example. But the answer is, yes, people have measured hyperperfusion in autistic’s brains:

Brain perfusion SPECT and EEG findings in children with autism spectrum disorders and medically intractable epilepsy

In specific, they found

The areas of hypoperfusion and EEG focus were highly related in seven of 12 children, while the areas of hyperperfusion were highly related to EEG focus in six of 12 children. The areas of hypoperfusion were highly related to the focus observed on EEG, but were not always related.

Using the simplistic logic of HBOT/autism promotors, one then is left with the question of whether could HBOT make seizure activity worse? I wouldn’t put too much weight on this question other than to point out that it isn’t 100% clear that there can be no downside to HBOT. The logic “there is hypoperfusion therefore HBOT should benefit” isn’t strong; the idea that “there are areas of hyperperfusion, therefore HBOT could have a downside” is also not strong. There are three other studies mentioning hyperperfusion and autism. And, I was interested to see that there are 350 hits for a search of hyperperfusion and epilepsy in pubmed. Compare this to 30 hits for autism and hypoperfusion.

Back to HBOT. There isn’t much science for HBOT, to be frank. Most of the momentum, at least in publications, is from one source: Dan Rossignol. An early paper: Hyperbaric oxygen therapy may improve symptoms in autistic children. by Dr. Rossignol was published in Medical Hypotheses–a pseudo medical journal. I believe Dr. Rossignol’s clinic in Florida provides HBOT.

While there have been articles like the above and some small open label study reports, true randomized trials have been lacking. A recent review Hyperbaric oxygen therapy for treatment of children with autism: a systematic review of randomized trials reported

While some uncontrolled and controlled studies suggested that HBO therapy is effective for the treatment of autism, these promising effects are not replicated. Therefore, sham-controlled studies with rigorous methodology are required to be conducted in order to provide scientific evidence-based HBO therapy for autism treatment.

Also worth noting is that HBOT is currently rated as “non-accepted” by the European Committee for Hyperbaric Medicine. An indication that there was not good evidence either way at the time they prepared their statement.

Two recent studies (the one which is the focus of this article and another) have used a more randomized/blind methodology and one has looked at biomarkers considered important in HBOT and autism (cytokines). The results have not been encouraging.

First the more biomarker based study. This group studied autistic children given HBOT and looked at cytokine levels (Brief report: Hyperbaric oxygen therapy (HBOT) in children with autism spectrum disorder: a clinical trial.) Per that study,

Ten children completed 80 sessions of HBOT and all improved by 2 points on the clinician-rated CGI-I scale (much improved) as well as several parent-completed measures of behavior. The lack of a control group limits the ability to determine if improvements were related to HBOT.

and also:

“Although this study was limited by the small sample size and by the variable nature of cytokines, we found no evidence that HBOT affects cytokine levels or that cytokine levels were associated with behavioral changes”

So, if there is a benefit from HBOT, it isn’t due to changes in cytokines. Which HBOT doesn’t seem to affect.

Another somewhat recent study attempted a clinical trial as well
Controlled evaluation of the effects of hyperbaric oxygen therapy on the behavior of 16 children with autism spectrum disorders. This study, out of the old “Thoughtful House” including Andrew Wakefield as an author found ” No consistent effects were observed across any group or within any individual participant, demonstrating that HBOT was not an effective treatment for the participants in this study. This study represents the first relatively large-scale controlled study evaluating the effects of HBOT at the level of the individual participant, on a wide array of behaviors.”

Finally, a study out in the past couple of months again attempts a randomized controlled study: “Hyperbaric oxygen in the treatment of childhood autism: a randomised controlled trial.” The study is out of Thailand. One factor of note is the attempt to do a real control using a “sham” air group. Obviously HBOT studies are complicated in that study subjects can easily detect the changes in pressure. Of note, HBOT in this case is 100% oxygen:

This study was a prospective, randomised, double-blind, controlled trial of HBOT at 153 kPa (1.5 ATA) with 100% oxygen for one hour daily, weekdays to a total of 20 sessions, versus a sham air treatment consisting of pressurised room air at 116 kPa (1.15 ATA) on the same schedule.

While some reports have used 100% oxygen at 1.5ATA, many have used either air or enriched air and sometimes lower pressure (1.3ATA). I.e. this study involves higher oxygen exposure than in many studies. Air is about 21% oxygen. So, a 1.5 atmospheres of pure oxygen is about 7.5 times the oxygen partial pressure in air. Many reports in early studies were about 1.3 ATA air or slightly enriched air. 1.3 ATA (atmospheres absolute) at 25% O2 is about 32% oxygen. For divers, these levels of oxygen are comparable to Nitrox or enriched air. One can get a higher oxygen level from a mask at 1 atmosphere. Which has been a critique of HBOT from the start. Early anecdotal reports from HBOT practitioners claimed that oxygen delivered by mask was not effective. Only high pressures gave whatever results were claimed. Which is counter intuitive to the simple explanations of how HBOT should work.

But, with both high pressure and pure O2, the Thailand study should provide clarity in these questions. Which begs the question, what are those results? The full paper is online and the abstract is below.

BACKGROUND:
Promising results with hyperbaric therapy for children with autism have been reported, but most involved the use of only mild pressure with oxygen supplementation. To date, there has been no randomised, blinded trial of 100% oxygen administered at hyperbaric pressure. This study evaluated the efficacy of hyperbaric oxygen therapy (HBOT).

METHODS:
Sixty Thai children with autism, aged three to nine years, were randomly assigned to receive 20 one-hour sessions of either HBOT at 153 kPa (1.5 ATA) or sham air at 116 kPa (1.15 ATA). Effects on behaviour were measured using the Autism Treatment Evaluation Checklist score (ATEC) and clinical improvement was measured with the Clinical Global Impression (CGI) system; in particular the clinical change (CGIC) and severity (CGIS) sub-scores. These were evaluated by parents and clinicians, both of whom were blinded to the actual exposure.

RESULTS:
The mean total ATEC scores by both parents and clinicians were significantly improved after intervention in both arms of the study compared to the score before intervention (P <; 0.001 in both groups by parents, P = 0.015 in HBOT group and P = 0.004 in sham group by clinician). There were no statistically significant differences in average percentage changes of total ATEC score and all subscales scores when comparing the HBOT and sham air groups, either by parents or clinicians. Changes in the CGI scores following intervention were inconsistent between parents and clinicians. For severity scores (CGIS), parents rated their children as more improved following HBOT (P = 0.005), while the clinicians found no significant differences (P = 0.10). On the other hand, for change scores (CGIC) the clinicians indicated greater improvement following HBOT (P = 0.03), but the parents found no such difference (P = 0.28).

CONCLUSIONS:
Children with autism who received 20 sessions of either HBOT or a sham air exposure had significant improvements in overall behaviour but there were no significant differences in improvement between groups. The inconsistent changes on CGI sub-scores between parents and clinicians are difficult to interpret, but no overall clinically significant benefit from HBOT could be shown. Both interventions were safe and well tolerated with minimal side effect from middle ear barotraumas.

Repeat for emphasis: “Children with autism who received 20 sessions of either HBOT or a sham air exposure had significant improvements in overall behaviour but there were no significant differences in improvement between groups”

Reports from parents and clinicians did not agree and the authors conclude “no overall clinically significant benefit from HBOT could be shown”.

HBOT is not cheap. A single “dive” can cost in the neighborhood of $100. Parents have purchased portable chambers which run in the $10-20k range (depending on model and whether new). And have modified these to provide O2 enriched air, outside the manufacturer’s specifications. There is a resale value in these chambers so far, so the net cost is not going to be as high. But, all told, there is substantial outlay of funds and time in HBOT. The science pro is shaky at best. And now there are two negative controlled trials.

These results will likely do little to dampen the enthusiasm for HBOT. All studies of HBOT and autism in clinicaltrials.gov are completed, so future data may not be forthcoming.


By Matt Carey

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41 Responses to “Hyperbaric oxygen in the treatment of childhood autism: a randomised controlled trial”

  1. livsparents October 24, 2012 at 23:49 #

    The results of the Thailand study beg the question. Is it the confinement and potential relaxation techniques applied during the dives the catalyst for better behaviors? I could get a nice pressure vest and a decent set of headphones for the price of a dive and achieve the same results.

  2. _Arthur October 25, 2012 at 01:21 #

    Using air enriched in O2 in a pressurized “tent” not specifically designed for oxygen seems a recipe for disaster. There already have been fires in purpose-designed hyperbaric O2 chambers.
    Unless the tent material is perfectly fireproof, that there is no leaks and that the compressor never causes sparks, and that stringent precautions are observed to prevent static electricity, and that no electrical devices whatsoever, including mp3 plates and cell phones are ever used inside the “tent”, and that its O2 enriched air is safely vented _outside_ after each use…

    …the mind reels, boggles & rattles.

    • Dr Rob Pender August 3, 2016 at 15:07 #

      If the chamber is pressurised with compressed air, and the oxygen is given via mask and concentrator, there would be no risk of fire.No oxygen is stored and with a breathe on demand no build up of O2

      • Chris August 4, 2016 at 14:46 #

        You missed this as you were skimming the Googles for four year old articles on HBOT:
        https://leftbrainrightbrain.co.uk/2009/06/14/2-fatality-hbot-fire/

        I have seen hyperbolic chambers during a tour of our local NOAA facility, and the ones used for the divers during the construction of a large local bridge…. and they are very small and confined. I doubt my autistic son would even try to get inside.

        You need to bring better scientific evidence than your declaration of “fact.”

  3. Science Mom October 25, 2012 at 01:26 #

    You are right Sullivan; this won’t deter anyone who is a true believer to stop using it. HBOT seems to be one of the most touted “autism treatments” and given the monetary investment, “clinics” aren’t going to want to reveal the evidence. And those who have purchased one for their private use aren’t going to want to believe they’ve been snookered.

  4. Lara Lohne October 25, 2012 at 06:56 #

    I believe subjecting my son to a hyperbaric chamber would do more harm to him then any even potential good. He gets anxious in bathroom stalls and elevators without windows. He’s been that way since he was really little, but I don’t know why. I honestly believe shutting in a device like this would traumatize him. He’s making amazing progress on his own. I’m not going to run the risk of messing that up and him regressing again. So no hyperbaric time for my son, particularly since it doesn’t work anyway.

    • chavisory October 28, 2012 at 13:55 #

      Lara, I have a similar aversion to enclosed spaces. I hesitate to call it claustrophobia, since it seems dependent not on the size of the space, but on either inability to escape if I need to, or lack of view of the outside (a small room with no windows is far worse than a small room with windows). I have no idea why, either. I was with three other autistic friends recently, and we all had the same bad reaction to a crowded elevator with no window.

      Something to think about, parents.

      • Lara Lohne October 28, 2012 at 17:12 #

        chavisory, yes, it isn’t the size of the space but the lack of windows and if there is a lot of noise (the can and bottle return area at the grocery story has always cause him to suffer a meltdown) that seems to aggravate it. He doesn’t like the sound of echos in a bathroom stall, nor the enclosed feeling of it either, but he seems to like echoy type spaces in general, just not when they are confined or enclosed and windowless. If he melts down when he’s just taken into a bathroom stall with me, I’m certainly not going to subject him to isolation in a hyberbaric chamber, that would be cruel, in my way of thinking.

  5. autismjungle October 25, 2012 at 07:25 #

    @livsparents, you are aware, I assume, of Temple Grandin’s squeeze machine?

  6. David Hall October 25, 2012 at 13:57 #

    I appreciate this open forum on HBOT studies and autism. May I direct you to view http://www.HBOT.com and dialogue with Dr. Paul Harch, himself a pioneer of HBOT treatment. In 1996, he was the first to treat an autistic patient with HBOT. Read about it on his website, and know that HBOT does, indeed, offer healing through PROPER and MEASURED treatment, frequency of “dives” (we’ve seen better brain damage recovery with 40 dives, not 20), and an M.D. trained in HBOT and autism. HBOT is not a simple on/off switch, you do in the home.

    Rather, Dr. Harch’s research and treatment is tailored to the patient, the degree and severity of conditions and symptoms and many other variables.

    While we offer no “Promise” of healing, we offer the promise of positive discovery on past patient outcomes and encourage you to call toll free to find out more, [edit: Matt Carey].

    • Lara Lohne October 25, 2012 at 17:40 #

      I take great offense in your referring to those with autism as having brain damage. My own son is not damaged and is funny, bright and affectionate. This, along with the fact that my son has sensitivity to enclosed spaces and darkness, is another reason I will never subject me son to this ‘treatment’. Because those who promote it don’t see my son as a fully functional person, but as someone who is damaged, and he is not damaged at all. My son doesn’t need healing, he is perfect the way he is, and is the way he was meant to be.

      • David Hall October 25, 2012 at 18:48 #

        I apologize for offending you. My intention this day was to share the promise of a hopeful treatment by a pioneer in HBOT. Should you choose to not use the info, that’s OK.

        If you knew of a promising treatment, wouldn’t you want to shout it, responsibly, from the rooftops?

        My specific Doctor, Dr. Harch, has a 25 year history of helping treat different conditions esp. focused on the brain. He, as a Doctor of Medicine believes that Autism and brain repair go together. I again, did not wish to upset you or any other reader, I just wanted you to be aware of this hopeful treatment for Autism.

    • Sullivan (Matt Carey) October 25, 2012 at 17:42 #

      David Hall,

      as a general rule, I don’t allow phone numbers in the comments. I have edited your comment and noted that. If this is not acceptable I can remove your entire comment.

      I am completely unsurprised that an HBOT article generated someone advertising his services. That has happened in the past. No matter that the discussion above shows a lack of efficacy.

    • chavisory October 28, 2012 at 13:57 #

      You “offer” healing, but you also “offer no ‘Promise’ of healing?” Okaaaaay…….

  7. Lawrence October 25, 2012 at 16:05 #

    @David Hall – I’d love to see the detailed research and mechanism by which HBOT is supposed to work…..

    • David Hall October 25, 2012 at 16:33 #

      Please visit our library of VDO and transcripts on Autism and HBOT at
      HBOT.com. We are on the same team here, looking to advance treatment for autism and have it reimbursable under Medicare coverage.

      • Lawrence October 25, 2012 at 17:34 #

        David – after going through PubMed, I find little or no actual evidence that shows that HBOT is effective. After looking at your website, I see testimonials, but no research or other reproducible evidence that shows that HBOT is effective, especially in cases of autism (especially given that the Study referenced above showed no evidence of effectiveness vs. placebo treatment).

        Care to explain?

      • Sullivan (Matt Carey) October 25, 2012 at 17:48 #

        David Hall,

        my team is very focused on accurate information. I don’t see that on your site. As far as autism goes, you have one letter from someone who has a financial interest in HBOT.

        If we are on the same team, as you say, here’s an offer I rarely make: You are free to take the article above for your site provided you include it in its entirety without any edits or comments for your autism info page, like you did with the letter from Trish Plank.

        Are we on the same team?

  8. lilady October 25, 2012 at 18:52 #

    I think Mr. Hall is in the same league as the PR person who kept promoting a quack doctor’s cancer treatment…totally clueless about autism and totally ignorant in basic science.

    How about the “problems” associated with this bogus autism treatment, David Hall?

    -Lowering of the seizure threshold for autistic kids with a concomitant diagnosed…or undiagnosed…seizure disorder.

    -Inner ear problems/dizziness associated with the Eustachean tube dysfunction

    Perhaps you could tell us how the good doctor manages to get frightened autistic kids into the HBOT chamber. Does he sedate them?

  9. David Hall October 25, 2012 at 18:58 #

    Lawrence, Matt.

    I seemed to have error’d in my effort to offer some information to your readers.
    Our Doctor, specifically, knows more than most in the nation about Autism and its relationship with healing with HBOT. Our website is not an Autism website, therefore we have articles, substance, vdos on many subjects and conditions. I apologize to you and your readers, I meant not to offend, I meant to shed light on HBOT efficacy as it relates to promising treatment for Autism.

    We are on the same team, we want accuracy and we are mostly focused today on TBI & PTSD as it relates to Iraqi and Afghanistan veterans. I can barely keep our website under control with the amount of content coming to us, so, at this time, thanks for the offer, but I will not commit to placing the article on our site, knowing it would not get done by our webmaster.

    We believe that HBOT under proper medical supervision (a big caveat), is a remarkable tool for healing many wounds of the body and mind. Thanks for allowing me to respond.
    Again, did not mean to get anyone upset, but I see I did, so I am sorry for that.

    • Lawrence October 25, 2012 at 19:00 #

      @David – there is a huge difference between pitching a marketing message & offering actual scientific evidence. I see none on your website or listed in PubMed.

      Perhaps you would care to point us to the various studies that show the efficacy of HBOT – especially for autism?

      • David Hall October 25, 2012 at 19:09 #

        Lilady,
        Did I insult you? I surely didn’t mean to. What good comes from you insulting me? You’ve let me know my comments are not welcome here. Thanks for being so clear on that. Truly sorry my desire to help or offer information has resulted in anger and name calling.

      • Chris October 25, 2012 at 19:20 #

        Actually your comments are very welcome. You just don’t seem to understand that they lack one very crucial thing: scientific evidence. So, please post the title, journal and dates of the PubMed indexed papers that support your claims.

      • David Hall October 25, 2012 at 19:21 #

        In response Lawrence, I reviewed our offers on Autism info,
        I saw no less than 9 website documents on the subject. These articles were not written by me. I ask you to review them and see what evidence there may be that could be of use to the community.

      • David Hall October 25, 2012 at 19:38 #

        Harch, PG brings up TBI and PTSD studies on PubMed.
        Nothing under Dr. Harch specific to autism on PubMed search.

      • Chris October 25, 2012 at 19:46 #

        This is a blog on autism, with specific requirements that claims be backed up with science. While it has its flaws, it is just better that you post the title, journal and dates of the PubMed indexed papers to support your claims here.

        Please do not make us wade through the morass of self-promotion of that website.

  10. Science Mom October 25, 2012 at 19:32 #

    Mr. Hall, what part of scientific evidence in the form of peer-reviewed publications are you having difficulty with? I see a lot of testimonials and self-promotion on that website but not a single shred of unbiased information. Why?

    • David Hall October 25, 2012 at 19:47 #

      Tough crowd today! Science Mom. Harch, PG on PubMed shows HBOT efficacy studies conducted by Dr. Harch. He’s not a quack as Lilady suggested above. You want unbiased information? My peer-reviewed publications are on the site, just not specific to Autism. The Doctor’s specialty is concussive brain injury. His hope and treatment possibility for Autism is just that. Black and white this is not. Steps in clinical research will lead to better evidence. I didn’t claim to have a shred of unbiased information. I only claim that Dr. Harch is a great researcher of HBOT impacted conditions, including autism.

      Part of the HBOT problem in mainstreaming is that the medical structure requires proof, unbiased information and not until that is satisfied, is there any interest in “connecting the dots” for hopeful treatment.

      I have learned a great deal in joining this blog today.
      Blessings to you, Science Mom and others on leftbrainrightbrain.
      Over and out.

      • Chris October 25, 2012 at 19:55 #

        So you cannot support your original claim with actual scientific evidence:

        In 1996, he was the first to treat an autistic patient with HBOT. Read about it on his website, and know that HBOT does, indeed, offer healing through PROPER and MEASURED treatment, frequency of “dives” (we’ve seen better brain damage recovery with 40 dives, not 20), and an M.D. trained in HBOT and autism.

        I hope that you learned that not everyone believes claims without evidence.

      • Science Mom October 25, 2012 at 20:05 #

        Tough crowd today! Science Mom. Harch, PG on PubMed shows HBOT efficacy studies conducted by Dr. Harch. He’s not a quack as Lilady suggested above. You want unbiased information? My peer-reviewed publications are on the site, just not specific to Autism.

        So that would be you don’t have a single publication with regards to HBOT effectiveness for treating autism correct? If someone is treating a particular disorder and making claims of effectiveness with zero evidence, that is a quack. Considering this is a blog about ASDs and related issues, don’t you think that providing acceptable evidence as it relates to autism is appropriate before vomiting out shameless PR for a for-profit clinic that has a vested interest?

  11. lilady October 25, 2012 at 20:50 #

    Yeah, such a “tough crowd today” Mr. Hall.

    So sorry we did roll out the red carpet for you and your Spam//sarcasm.

    http://www.linkedin.com/pub/david-h-hall/13/97/103

    • David Hall October 25, 2012 at 21:02 #

      I wish you peace and love and treatments that are effective.

      Namaste.

      • Lawrence October 25, 2012 at 21:23 #

        Wow – I didn’t realize asking for evidence was “name-calling & insulting.”

      • Sullivan (Matt Carey) October 25, 2012 at 22:57 #

        David Hall,

        I know all too well that it is sometimes a bit of a shock to make a statement you think is going to be easily accepted by the target audience, only to find that it actually is controversial. But, I would ask, did you read the article above or did you just see that it was about HBOT and autism and decide to respond? I did not take a contentious tone above, but I did make it clear that HBOT and autism is not well supported either theoretically or in practice.

        Take a moment to reflect on this discussion: the autism parents you are probably familiar with are naturally those who are seeking you out. But that is not a big fraction of the population. Seriously, how many HBOT centers are there? With a few million autistics in the US, clearly most are not seeking you out. We have had therapy after therapy promoted without good reason or evidence. Some of which are clearly wrong and some of which have been harmful.

        In your first comment you stated, “Rather, Dr. Harch’s research and treatment is tailored to the patient, the degree and severity of conditions and symptoms and many other variables.”

        People reading that are going to want to know–how do you tailor HBOT to autism? There is no good theory behind it and the data are negative?

        In the informed consent category, now that you’ve read about clinical trial of HBOT which were not favorable, will you make that information available to your clients on your website and/or in future talks? Seeing no mention of this from you, of course commenters on this site are skeptical.

      • David Hall October 26, 2012 at 15:20 #

        JOURNAL OF NEUROTRAUMA 28:1– (XXXX 2011) a Mary Ann Liebert, Inc.
        DOI: 10.1089/neu.2011.1895
        A Phase I Study of Low-Pressure Hyperbaric Oxygen Therapy for Blast-Induced Post-Concussion Syndrome and Post-Traumatic Stress Disorder

      • Chris October 26, 2012 at 16:37 #

        Traumatic brain injury is not autism. If you are equating autism with traumatic brain injury, then there is no reason to believe any of the testimonies on your website.

      • David Hall October 26, 2012 at 16:45 #

        That’s our best work so based on the all the previous dialogue, wanted you to have it as a resource.

      • Sullivan (Matt Carey) October 26, 2012 at 18:49 #

        David Hall,

        I don’t have a problem with HBOT for demonstrated good uses. I used to belong to the real DAN (Diver’s Alert Network) specifically for the insurance if I needed to do a chamber ride. I’ve been on a plane where the flight was delayed while they took out seats to make room for a gurney and flew low to keep cabin pressure high while they took that diver to the nearest chamber (800 miles away).

        I also have a disabled kid. Here’s a calculus that goes on in my head. I believe that for every $10,000 I can set aside now, my kid will spend 1 fewer year in poverty. And that’s not accounting for the possibility of lower government assistance in the future. $10k to improve someone’s quality of life over a lifetime would be worth the exchange. But I don’t see evidence of it for HBOT and autism. By your account, your group has been doing this for 16 years. On anecdote and hope. Now you have data. What are you doing in the future?

  12. Lawrence October 26, 2012 at 16:57 #

    @David – so what you are saying is that you have no research relating to autism…..good to know.

  13. Science Mom October 26, 2012 at 18:15 #

    That’s our best work so based on the all the previous dialogue, wanted you to have it as a resource.

    You should have stuck the Namaste David. Look, we are sceptics here and most that comment here are autists or parents of autists and/or special needs children.

    In other words, we aren’t rubes David. Sullivan presented the evidence for HBOT as an autism treatment and the evidence thus far and the best designed studies do not show any benefit whatsoever. What have you got?

Trackbacks/Pingbacks

  1. FDA Warns Consumers About Common Off-Label Autism Therapy | Today Health Channel - August 24, 2013

    […] autism argue that the controversy around it is “political, not scientific.” But that’s not actually the case. In addition to the risks associated with HBOT, all of which at the least involve pain and […]

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