Ozone therapy updates & Adjunctive treatments Dr Adam Weglein Regenerative Ortho Med Houston Texas www.houstonsportsdoctor.com

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

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

PRP Has been used for over 10yrs in humans, 1987 started Ferrari et al. Marx et al. 1998- PRP increasing rate bone graft maturity of dental implants compared to control

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

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

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):1414-21

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

Review of current literature Tendon Aspenberg et al 2004 -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

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

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.

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

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)

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)

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

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)

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)

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

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

What’s new??

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. 1989 Jan; 83(1):129-38. Plasma buffer system(antioxidants and polyunsaturated fatty acids)-> H2O2 Ozone breaks down to ROS ROS are neutralized when mixed with plasma within 30sec- 1min

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.

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:  10.1186/2045-9912-1-29 PMCID: PMC3298518 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)”

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

Ozone safety study Interv Neuroradiol. 2011 September; 17(3): 281–285 Ozone safety study Interv Neuroradiol. 2011 September; 17(3): 281–285. Published online 2011 October 17. PMCID: PMC3396043 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.

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

Rev Esp Cir Ortop Traumatol. 2013 Aug 4. pii: S1888-4415(13)00097-0 Rev Esp Cir Ortop Traumatol. 2013 Aug 4. pii: S1888-4415(13)00097-0. doi: 10.1016/j.recot.2013.06.003. 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

3 reported spine infection from 02-02 intradiscal L5-S1 achromobacter Xylosoxidans infection secondary to 02-03 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 02-03 developed chronic osteomyelitis- septic discitis (AX)-> getting a spine fusion 3 reported spine infection from 02-02 intradiscal

Disc herniation Intramuscular o2,03 Global posture re education An observational retrospective study to compare 02-03 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

reduced TNF-α concentrations as well as TNF-α and IL-1β mRNA levels Vaillant JD, et al Eur J Pharmacol. 2013 Aug 15;714(1-3):318-24. doi: 10.1016/j.ejphar.2013.07.034. 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

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.

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

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.

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.

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 NCT00832312.

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

Thank you Questions?