1. Ozone therapy updates & Adjunctive treatments
Dr Adam Weglein
Regenerative Ortho Med Houston Texas

2. Outline Some exciting updates on ozone research in the past year
Things that are being used with ozone treatments

3. PRP-Platelet Rich Plasma
Definition of PRP: 200,000 Platelets/ micoliter( Red Cross)
Two spin
1 st Separates RBC from plasma
2nd Separates (Platelets , WBCs )
do not mix anesthetic- prp Full activity at 6-8 weeks
4-10 times baseline platelet count- angiogenesis
Giusti I et al transfusion 2009;49(4): 771-8
Kevy et al. J Extra Corp technol 2004;36(1):28-35

4. PRP
Has been used for over 10yrs in humans, 1987 started Ferrari et al.
Marx et al PRP increasing rate bone graft maturity of dental implants compared to control

5. Platelets Circulate for 7-10 days
Contain 800 proteins with 1,500 bio active factors
Growth factors, peptide hormones, chemoattractants- macs, neutrophils, stem cells

6. Alpha Granules
Tendon healing
Platelet derived growth factor (PDGF)
Transforming growth factor (TGF)-Epidermal growth factor (EGF)
Vascular endothelial growth factor (VEGF)
Fibroblast growth factor (FGF)
Connective tissue growth factor (CTGF)
IGF
Dense Granules
Serotonin
ADP
Histamine
Calcium
Mag
Cell migration & proliferation
Lamda granules
Remove infection
Plasminogen- fracture repair

7. TGF-B Increasing collegen production, decreased onset of OA
Transforming growth factor (TGF)-increase type 1,type 3collegen production in tendons (mauri et al)
TGF-b 1 increased collagen synthesis in medial collateral ligaments and ACL fibroblasts in dose dependant
Mouse TGF-B decreased onset of OA
Marui et al J Orthop Res1997;15(1):18-23
Blaney et al. Ann Rheum Dis2006;65(11):

8. Review of current literature
PRP- Tendon proliferation
Wang et al. – promote human tenocyte proliferation & collagen synthesis, differential of tendon stem cell->active tenocytes ‘
Bosch et al.- flexor tendon horses. Statistically sig improvement collagen, gag, DNA in PRP vs control and > strength to failure

9. Review of current literature
Tendon
Aspenberg et al Found to improve achilles tendon repair callas strength at 3wk
Sadoghi et al showed rotator cuff fibroblast human dose dependant increase proliferation( DNA/ GAG ratio- marker of tendon degeneration) when exposed to PRP 5 times normal plasma

10. Review of current literature
Tendon
Mishra et al. 20 pts tennis elbow, refractory to PT, pain 15 months. PRP vs bupivicaine-> 8wks 60% improved mayo elbow score vs 16% VAS- 25.6months 93% pain

11. Review of current literature
Tendon
Peerboooms et al. PRP vs corticosteroid, pain 6mts tennis, 100 pts, double blind, randomized control- 2 year follow. PRP reduced pain and increased function exceeding cortisone out to 2 yrs.

12. Review of current literature
PRP- do not combine with local anesthetic ( Carofino et al ) single spin with bupivicaine vs steroid, saline no difference at 3 months (JAMA 2010, krogh et al 2013)
PRP vs whole blood injection greater reduction in pain at 6 wks post PRP Thanasas et al 2011

13. Review of current literature
Patella tendon
(Filardo et al). 15pts prp vs physical therapy. Greater level of sport activity at 6mts
PRP vs ECSW patella tendon 6, 12 mts > vas (vetrano castorina et al 2013)

14. Review of current literature
Rotator cuff partial tear
PRP vs dry needle 39 pts 9 2 week, 3 & 6 month, PRP improved SPADI score ( lyras et al 2009) & Rha et al 2013
Positive ultrasound echo pattern seen post prp( finnoff et all 2011)

15. Review of current literature
Ulnar collateral injury
MRI confirmed partial tear
88% returned to play 12 weeks post ( podesta et al 2013)

16. Review of current literature
Joint, cartilage damage, meniscus
Ishida et at. Regenerative meniscus cell in vitro
PRP decreased inflammatory IL-1 in OA chondrocytes, nfk
100pt 3 PRP knee joint, IKDC, VAS statistically improved at 6mth and one year (kon et al 2010)

17. Review of current literature
Joints
Prospective cohort study 20pts, 15 had benefit out to 1 year womac and post MRI follow up no change 77%( Halpern et at 2013)

18. Review of current literature
PRP vs HA injection
Prospective comparative study 150pts , 3 prps, vs Hm-HA, LW- HA, PRP > 82% vs 64% in HA groups VAS at 6 months ( Kon et al. 2011)
Spakova et al. PRP vs HA 120 pts. PRP > VAS, WOMAC at 6mts

19. Review of current literature
Hip OA
3 prp 30% improved womac at 6 months
Ankle OCL- (mei- dan et al 2012) –statistically better than HA

20. What’s new??

21. Ozone with blood Functional evaluation of complete sciatic, peroneal, and posterior tibial nerve lesions in the rat. Bain JR, Mackinnon SE, Hunter DA Plast Reconstr Surg Jan; 83(1):
Plasma buffer system(antioxidants and polyunsaturated fatty acids)-> H2O2
Ozone breaks down to ROS
ROS are neutralized when mixed with plasma within 30sec- 1min

22. Bocci V. Ozone-A New Medical Drug. Dordrecht: Springer; 2005
ozone concentration is less than 80 μg/ml, the buffer system and antioxidant system in blood and red blood cells can resist the damage to tissues and cell by ozone, thus fulfilling ozone treatment
The joint antioxidant system can become activated and provide a long lasting antioxidant response.

23. Med Gas Res. 2011; 1: 29. Published online 2011 December 20. doi: 10
Med Gas Res. 2011; 1: 29. Published online 2011 December 20. doi:  / PMCID: PMC Mechanisms of Action Involved in Ozone Therapy: Is healing induced via a mild oxidative stress? Masaru Sagai
Severe oxidative stress activates nuclear transcriptional factor kappa B (NFκB), -> inflammatory response and tissue injury via the production of COX2, PGE2, and cytokines
“moderate oxidative stress activates another nuclear transcriptional factor, nuclear factor-erythroid 2-related factor 2 (Nrf2). Nrf2 then induces the transcription of antioxidant response elements (ARE). Transcription of ARE results in the production of numerous antioxidant enzymes, such as SOD, GPx, glutathione-s- transferase(GSTr), catalase (CAT), heme-oxygenase-1 (HO-1), NADPH-quinone-oxidoreductase (NQO-1), phase II enzymes of drug metabolism and heat shock proteins (HSP)”

24. Is medical ozone safe?
-Rat OA injected with ozone injection 3/ week for 3 weeks compared with MIA
Rats killed 40 days, articular cartilage and surrounding tissues were studied histologically. No signs of histologic changes seen

25. Ozone safety study Interv Neuroradiol. 2011 September; 17(3): 281–285
Ozone safety study Interv Neuroradiol September; 17(3): 281–285. Published online 2011 October 17. PMCID: PMC Effects of Ozone on Sciatic Nerve in Rat Q. Lin, H. Chen et al. Y
Our initial study suggests that ozone concentrations from
10 μg/ml to 80 μg/ml injected around rat’s peripheral nerve will not cause serious sequelae or serious damage to the structure and function of peripheral nerve.

26. Ozone on pain
Analgesic- oxidation of pain mediators- published: IM ozone in lumbar and c spine having pain reduction lasting 2 yrs.
Anti-inflammatory-oxidize arachidonic acid- prostaglandins, IL-1, IL-2, IL-8
Improves microcirculation- improve oxygen to tissue for healing, hypoxic pain response

27. Rev Esp Cir Ortop Traumatol. 2013 Aug 4. pii: S1888-4415(13)00097-0
Rev Esp Cir Ortop Traumatol Aug 4. pii: S (13) doi: /j.recot
paravertebral and intra-abdominal abscess due to oxygen- ozone therapy for lower back pain.
Complications secondary to oxygen-ozone therapy are rare, but they have been described in medical literature. There are only two cases of infectious complications after oxygen- ozone therapy

28. 3 reported spine infection from 02-02 intradiscal
L5-S1 achromobacter Xylosoxidans infection secondary to therapy for the treatment of lumbosacral disc herniation: A case report and review of the literature2013
AX opportunistic pathogen aquatic, rare cause of osteomyelitis, 1st reported case of discitis from AX
29 yo post developed chronic osteomyelitis- septic discitis (AX)-> getting a spine fusion
3 reported spine infection from intradiscal

29. Disc herniation Intramuscular o2,03 Global posture re education
An observational retrospective study to compare and/or global postural re-education in complicated chronic low back pain. Apuzzo et al, func neurol 2014 mar 5:1-9
Disc herniation
Intramuscular o2,03
Global posture re education
Combo of both showed the best long term, yrs improvement

30. reduced TNF-α concentrations as well as TNF-α and IL-1β mRNA levels
Vaillant JD, et al Eur J Pharmacol Aug 15;714(1-3): doi: /j.ejphar Epub 2013 Jul 31
Ozone oxidative postconditioning ameliorates joint damage and decreases pro-inflammatory cytokine levels and oxidative stress in PG/PS-induced arthritis in rats.
reduced TNF-α concentrations as well as TNF-α and IL-1β mRNA levels

31. Effects of ozone applied by spinal endoscopy in patients with chronic pain related to failed back surgery syndrome: a pilot study.
Pts with persistent chronic pain (more than six months) in the lumbar region and in the lower limbs related to failed back surgery syndrome (FBSS)
Overall, the patients had 43.7% reduction of lumbar pain, 60.9% reduction in leg pain in six months followed by 44.0% of improvement in ODI.

32. Effects of laser and 03 on bone healing in the calvarial defects
Kazancioglu et al 2013
Low level laser and 03 improved bone healing, 03 improved more at 1 month compared to control

33. The effects of N-acteylcysteine and 03 on oxidative stess/ inflammation in tylenol induced nephrotoxic model
NAC and OT prevented renal injury in rats, reduced inflammation, improve renal damage anti oxidant.

34. The effect of IA of different concentration of 03 on TNF-, TNF-r1, tnf-r2 in rat RA chen et Rheumatol int may 2013
Conclusion intra articular injection of 03 at 40ug/m can effectively suppress the joint swelling from RA, down regulating TNF-a, TNF-r2 and up regulating tnt-r1 in the joint.

35. On going research
Intraarticular O3 therapy for pain control in osteoarthritis of the knee: Ozone is being currently tested for its effectiveness in relieving the pain in patients suffering from osteoarthritis of the knee. The current status of the study is phase 2 which is sponsored by Ben-Gurion University of the Negev and the study being conducted by NCT

36. Putting it together Combing HA+ PRP+ ozone in joints?
Mixing ozone with stem cell??
Traditional prolotherapy + ozone vs prolozone??
Other possible ideas testosterone prolotherapy??
Exciting times ahead in Regenerative Medicine

37. Thank you
Questions?