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

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Presentation on theme: " Ozone therapy updates & Adjunctive treatments Dr Adam Weglein Regenerative Ortho Med Houston Texas"— Presentation transcript:

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  2 nd 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):  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. 2012) 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 μ g/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: / PMCID: PMC Mechanisms of Action Involved in Ozone Therapy: Is healing induced via a mild oxidative stress? Masaru Sagai / Masaru Sagai  Severe oxidative stress activates nuclear transcriptional factor kappa B (NF κ B), -> 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 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 Q. Lin, H. Chen et al.  Our initial study suggests that ozone concentrations from  10 μ g/ml to 80 μ g/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 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 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, 1 st 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 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 Vaillant JD,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-1 β 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?

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