Dear Sean, I agree with you completely about the good evidence for HBOT and decompression illness and HBOT for diabetic leg ulcers and radiation proctitis, and as you said, debatable good evidence for carbon monoxide poisoning. I'm not so sure about the robustness of the evidence for the use of HBOT in the other conditions you cite. Apart from all the systematic reviews on HBOT done by Mike Bennett, I'm sure you have seen this recent 2008 HTA from NHS Quality Scotland: The clinical and cost effectiveness of hyperbaric oxygen therapy (HBOT) (PDF, 1MB, 2mins, 29secs) I'm also pretty sure you have seen this 2006 horizon scanning document from the AHRQ, USA commissioned by MEDICARE/MEDICAID: http://www.cms.gov/determinationprocess/downloads/id42TA.pdf Regards, Ash Dr Ash Paul Medical Director NHS Bedfordshire 21 Kimbolton Road Bedford MK40 2AW Tel no: 01234897224 Email: [log in to unmask] ________________________________ From: Seán <[log in to unmask]> To: [log in to unmask] Sent: Thu, 17 June, 2010 10:54:07 Subject: Evidence and HBOT Subject: Re: Popular but ineffective treatments? Following on from Ozone, how about including Hyperbaric Oxygen Therapy (HBOT) Paul? It's supposed to cure everything from A to Z, including spider bites, and on the basis of what evidence, dare I ask? Michael Bennett who has done monumental work on systematic reviews for HBOT, and who is a member of this Group will support my statement, I'm sure. I'm copying Mike into this email as well, in case he misses this group posting. Regards, Ash Dr Ash Paul As an ex/occasional-diving and hyperbaric doc, I’m sure it’s possible to work as an HBOT physician and be a practitioner of EBM. I think you’ll find that’s Mike Bennett’s position too – hope he won’t mind me saying so. I don’t think you’ll find any reputable person in the field believing “It's supposed to cure everything from A to Z” – I’m sure you didn’t mean to characterise them as such. There are well-publicised lists of approved indications, some with more evidence to support them than others. Like all practitioners of EBM, one works on the understanding that evidence will accrue that may result in continued use of the treatment, or its abandonment. Such is life. So, for the record, HBOT is the gold-standard treatment of choice for decompression illness, and not referring for treatment would probably be seen as negligent. As in much of medicine, there is little high quality evidence, and it is difficult to attract funding for the necessary large RCTs. Therein lie the problem: while HBOT remains a specialty practiced on the fringes of the NHS it will continue to struggle to attract such funding, and without better evidence it will find it difficult to position itself in the mainstream. As you rightly say there are a number of Cochrane reviews of HBOT evidence, and most have Mike Bennett’s name on them somewhere. These demonstrate: Some evidence of benefit in soft tissue radiation damage, tumour sensitization to radiotherapy, traumatic brain injury, idiopathic sudden onset sensorineural hearing loss and tinnitus, chronic wounds in diabetics or secondary to venous disease, and acute coronary syndrome! Possible benefit in thermal burns, acute migraine, and stroke. No benefit in fracture healing, dental implants, carbon monoxide poisoning (although debate continues in the field about this..), malignant otitis externa, delayed onset muscle soreness, and multiple sclerosis. There are at least a couple more reviews in production AFAIK. And it’s only the Loxosceles reclusa (Brown Recluse) spider! Seán Hopson