Clinical utility of ozone therapy for musculoskeletal disorders

Abstract

Oxygen-ozone (O3) therapy serves as an alternative medical technique that increases the oxygen in the body along with the introduction of O3. O3 therapy has finally reached a level where the biological mechanisms of action have been understood, showing that they are in the domain of physiology, biochemistry, and pharmacology. Few clinical applications have been reviewed here as well as exemplifying that O3 therapy is particularly useful in musculoskeletal disorders. In the therapeutic range, O3 can be used as a more effective and safe substitute of standard medications. O3 therapy has been used for many years for its ability to inactivate various viruses, cancer, and acquired immune deficiency syndrome but is now making strides in the treatment of musculoskeletal disorders such as rheumatoid arthritis, lumbar facet joint syndrome, subacromial bursitis, carpal tunnel syndrome, osteoarthritis, hip bursitis, shoulder adhesive capsulitis, herniated disc, and temporomandibular joint disorder.

Full text

© 2018 Medical Gas Research | Published by Wolters Kluwer - Medknow 103
REVIEW
INTRODUCTION
Ozone (O3) has great oxidizing activity as a soluble gas. When
in contact with biological uids, it forms reactive oxygen
species as well as lipid oxidation products.1 Both of these
products react with white blood cells initiating the formation
of proteins, cytokines, and red blood cells which increases the
tissue oxygen supply. O3 is used to treat many cases regarding
the muscles, tendons, and joints. O3 therapy raises the pain
thresholdas it works based on stimulating antinociceptive ap-
paratus mediated by serotonin and endogenous opioids. Due
to neoangiogenesis, O3 allows for vascularization caused from
tissue hyperoxygenation. Therefore, the inhibitory capacity of
inammatory metabolites is improved as well as local tissue
trophism. There is a common theme among many literature
reports that O3 reduces local pain which favors the mobility
lost during the painful state and recovery of joint function.2,3
O3 can be injected by peri-articular, intra-articular, or percu-
taneous means. It is considered a satisfactory treatment with
a low risk of complications and high success rate.
MECHANISM OF ACTION
An endogenous cascade is started when beginning the use
of O3 therapy. In response, a stress is induced from the bio-
logically active substrates that are released. Because of O3’s
ability to dissolve in the aqueous component of plasma, it can
cause this oxidative stress.4 Hydrogen peroxide and a reac-
tive species (ROS) are formed when O3 reacts with water and
polyunsaturated fatty acids. When inhaled, the O3 reacts with
polyunsaturated fatty acids that are found in the alveolar lin-
ing layer. A mixture of lipid ozonation products (LOP) is also
formed simultaneously such as malonlydialdehyde, lipperoxyl-
radicals, hydroperoxides, isoprostanes, 4-hydroxynonenal, and
alkenals.5 The activation of the transcriptional factor mediating
nuclear factor-erythroid 2-related factor 2 (NRF2) is increases
with the moderate oxidative stress caused by O3. The role of
NRF2 is to activate the transcription of antioxidant response
elements. A variety of antioxidant enzymes attain an increased
concentration level upon introduction of antioxidant response
elements. Some of the antioxidants include glutathione S-
transferase (GST), catalase (CAT), heme oxygenase (HO)-1,
superoxide dismutase, glutathione peroxidase, heat shock
proteins and quinone-oxidoreductase. most of these enzymes
play a role as free radical scavengers in a range of diseases.5
Depending on the cell’s redox status and the amount given,
O3 and other medical gases such as nitric oxide and carbon
monoxide have a twofold effect. O3 overexpresses HO-1 or
heat shock proteins (HSPs) of 32 kPa which produces nitric
oxide.6 The expression levels of Hsp70 are upregulated by O3
which is related to HO-1. Therefore, there may be a develop-
ing role in therapy of free radical-based diseases. Heme is
enzymatically degraded by HO-1 and can be toxic depending
on free iron, amount produced, and bilverdin. Biliverdin is
a neutralizer of nitrosative and oxidative stress based on the
ability to interact with reactive nitrogen species and NO.7,8 It
was found recently that the heat shock response provided a
cytoprotective state during aging, cancer, neurodegenerative
disorders and inammation.9 Throughout the phylogenetic
spectrum, HO isoforms are found to be as regulators of redox
homeostasis and dynamic sensors of cellular oxidative stress.
Hormesis is a defense mechanism for oxidative insults to
Clinical utility of ozone therapy for musculoskeletal
disorders
Omar Seyam1, Noel L. Smith2, Inea Reid1, Jason Gandhi1, 3, Wendy Jiang1, Sardar Ali Khan1, 4, *
1 Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA
2 Foley Plaza Medical, New York, NY, USA
3 Medical Student Research Institute, St. George’s University School of Medicine, Grenada, West Indies
4 Department of Urology, Stony Brook University School of Medicine, Stony Brook, NY, USA
*Correspondence to: Sardar Ali Khan, MD, FRCS, FACS, skysalik@gmail.com.
orcid: 0000-0002-4759-530X (Sardar Ali Khan)
Oxygen-ozone (O3) therapy serves as an alternative medical technique that increases the oxygen in the body along with the introduction of
O3. O3 therapy has nally reached a level where the biological mechanisms of action have been understood, showing that they are in the
domain of physiology, biochemistry, and pharmacology. Few clinical applications have been reviewed here as well as exemplifying that O3
therapy is particularly useful in musculoskeletal disorders. In the therapeutic range, O3 can be used as a more effective and safe substitute
of standard medications. O3 therapy has been used for many years for its ability to inactivate various viruses, cancer, and acquired immune
deciency syndrome but is now making strides in the treatment of musculoskeletal disorders such as rheumatoid arthritis, lumbar facet
joint syndrome, subacromial bursitis, carpal tunnel syndrome, osteoarthritis, hip bursitis, shoulder adhesive capsulitis, herniated disc, and
temporomandibular joint disorder.
Key words: oxygen-ozone therapy; osteoarthritis; herniated disc; carpal tunnel syndrome; lumbar facet syndrome; muscle oxygenation,
bromyalgia; cervical disc herniation
doi: 10.4103/2045-9912.241075
How to cite this article: Seyam O, Smith NL, Reid I, Gandhi J, Jiang W, Khan SA. Clinical utility of ozone therapy for musculoskeletal
disorders. Med Gas Res. 2018;8(3):103-110.
Abstract
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multiple organ systems.9 O3 can have a role in hormesis by
regulating the proinammatory and anti-inammatory effects
of prostaglandin formation which is of similar nature to nitric
oxide.10
How O3 helps repair musculoskeletal tissues (tissue repair)
When O3 gets in contact with organic uids such as plasma,
lymph, urine, and saliva, it interacts highly with all tissue
components.11 It can react with antioxidants, glutathione, cys-
teine, albumin, ribonucleic acid (RNA), and deoxyribonucleic
acid (DNA).12 All these reagents, participate in the ozonation
process and formation of lipid oxidation products and ROSs.11
These two molecules function as biochemical regulators of
inammation and physiological concentrations.11 ROS are
described as being highly unstable, immediate action and a
half-life less than one second.12 It is common that patients re-
port the sensation of well-being during the course of O3 therapy
and this is due to the LOPs which stimulate the central nervous
system and endocrine system while also improving hormonal
production, neurotransmitter release, and metabolism.11 It was
proved that O3 was capable of promoting the preservation and
increase of endogenous antioxidant systems through a study
conducted by Re et al.13 Another study which dealt with the
ozonation of platelet-rich plasma samples results demonstrated
the increase of interleukin (IL)-8. The increase of IL-8 allows
for the leukocytes to leave the circulation into the tissues to
facilitate the phagocytosis of bacteria and necrotic tissue of
ulcers.14 The results also showed an increase in growth factors
such as platelet derived growth factor (PDGF), IL, and trans-
forming growth factor beta (TGF-β) 1.14 Lim et al.15 that when
dermal wounds were exposed to O3, it increased the activity of
factor nuclear kappa B, an important immunomodulatory of
inammation and the expression of TGF-β which is essential
for remodeling tissue.
Temporomandibular joint disorder (myofascial pain syndrome)
The temporomandibular joints are the joints that connect the
jawbone to the skull. Temporomandibular joint disorder also
known as myofascial pain syndrome results in pain that limits
chewing, talking, and other daily activities. It was found that
the use of O3 therapy has been much more effective than medi-
cation therapy in patients with high pain scores which relieves
pain and increases the maximum voluntary interincisal mouth
opening values. A proposed explanation of why O3 causes the
joint to heal quicker than of the traditional therapy is due to the
highly reactive nature of O3. It is able to stimulate the broblas-
tic joint repairing abilities when injected into a joint capsule. It
is also able to promote new cartilage growth as well as reducing
inammation. When split into separate oxygen atoms, O3 is
able to react when in contact with a contaminant.16-18 In fact,
it never fails to initiate this reactive activity. A recent study
found that 87% patients had either improved or completely
recovered from temporomandibular pain.18 It was concluded
that this was a promising new treatment, but the mechanism
of action is still being researched. A plausible mechanism can
be due to a single oxygen atom oxidizing the contaminants. It
is thought that O3 can stimulate the broblastic joint since it is
such a reactive molecule. O3 can react with the contaminant
when it splits into single oxygen atoms.18
Herniated disc (back pain)
The herniated disc is characterized as a condition affecting the
spine in which a tear in the brous ring of an intervertebral
disc allows the central portion to bulge out.19 The treatment of
lumbar disc herniation is applied with a needle which is placed
into the hernia between the inner margin of the facet joint and
the lateral nerve root. This has been considered a minimally
invasive treatment for nerve root treatment since the O3 is mini-
mally invasive and the needle is thin. The mechanism of action
is as follows: nucleur pulposus is oxidized by proteoglycan
which then cause it to denaturize and reduce in volume. The
local blood circulation will have reduced when the osmotic
pressure is reduced. The doze of O3 administered is essential
and should not pass the capacity of glutathione and antioxi-
dant enzymes to prevent accumulation of hydrogen peroxide
and superoxide anion which can possibly degradation of cell
membranes.20 O3 in a medium of pH = 8 or higher will cause
the formation of free radicals. While, in a medium of pH =
7.5 or lower the formation of peroxides occur due to the ozon-
olysis mechanism. In oxygen-O3 therapy, O3 is administered
at a nontoxic concentration of 1 to 40 µg of O3 per milliliter
of oxygen. It was found through in studies that consisted of
in vitro on resected human disk specimens as well as in vivo
on rabbits that the optimal concentration to administer is 27
µg. O3 has a direct effect on the disk’s nucleus pulposus spe-
cically in proteoglycans at this concentration which results
in subsequent cell degradation of the matrix and release of
water molecules.21 The matrix is replaced by brous tissues
and formation of new blood cells in approximately 5 weeks.
A reduction in disk volume is the result of all these events. In
a study conducted by Andreula and others,22 ve histologic
disk specimens were removed during surgical microdiske-
cotmy who received intradiscal injects of O3 at 27 µg/mL.
Dehydration of the brillary matrix of the nucleus pulposus,
signs of regression (fragmentation and vacuole formation), and
revealing collagen bers were all noted in these specimens.
Other ndings of a herniated disk untreated with medical
O3 are proliferating and signs of new blood cell formation
guided by lymphocyte inammatory tissue and chondrocyte
hyperplasia. One of the main therapeutic causes of medical
O3 is a reduction in disk size which can possibly reduce nerve
root compression. Furthermore, disk shrinkage can improve
local microcirculation and increase the supply of oxygen by
reducing venous stasis caused by disk compression of vessels.
O3 therapy also had analgesic and anti-inammatory effects in
treating disk herniation.23 The action ties into inhibiting release
of bradykinin or release of algogenic compounds as well as
inhibiting synthesis of proinammatory prostaglandins. Proin-
ammatory cytokines such as interleukin can be neutralized by
increasing release of antagonists. The results from this study
was satisfactory compared to other percutaneous treatments
for disk herniation such as enzymatic chemonucleolysis.24 The
two procedures are similar, however oxygen-O3 therapy is less
invasive due to the narrow nature of the needle and less trau-
matic.25 Also, there were no anaphylactic or allergic reactions.25
Shoulder (Glenohumeral joint)
The shoulder allows for the role of orientating the hand and
has a great degree of movement.26 Specically, the glenohu-
meral joint is not a stable ball-and-socket joint, but has high
mobility.26 The rotator cuff muscles allow for joint motility.
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These muscles include the infraspinatus, subscapularis, su-
praspinatus, and teres minor. O3 therapy for the glenohumeral
joint includes injection with the posterior approach under the
inferior margin laterally using a 22 G needle. In a case study,
Benvenuti27 reported that a 58-year-old woman experiencing
severely limited joint movement and pain underwent a session
of O3 therapy with 10 mL gas mixture at a concentration of 15
µg/mL. Furthermore, it is helpful to puncture the long head of
the bicep muscle and subacromial bursa with a 27 G needle in
microdoses of 0.5 to 1 mL. After one week, the patient reported
a reduction of nocturnal pain.27 The patient reported a recovery
of active shoulder function and total reduction of pain.
Shoulder adhesive capsulitis
Shoulder adhesive capsulitis is a condition where there is a
reduction in the arc of active motion.28 Adhesive capsulitis is
characterized with an unknown etiology that has an onset of
pain associated with it.28 The treatment with oxygen-O3 can
help in the reduction of pain as well as inammation activ-
ity. It uses a mixture which is 95–96% oxygen and 4–5% O3.
The reduction and modulation of inammation activity and a
reduction of pain are a few of the many action accomplished
with medical O3. The local injection of O3 destroys algogenic
substances, alters serotonin, and inactivates bradykinin. All
of these substances are altered to produce no pain. A release
of soluble receptors or anatagonists neutralize proinamma-
tory cytokines such as interferon-a, tumor necrosis factor-α
(TNF-α) and ILs. In addition, the denaturation of cellular pro-
teins such as kallikrein, kininogen, and cyclooxygenase (COX)
help form endorphins and modify the pain receptors. Another
important activity is given by the muscle relaxant action by
direction action on the muscle bers.12 Contraindication to
this treatment include latent hypoglycemia, hyperthyroidism,
favism, pregnancy, and sickle cell anemia. This study has
many limitations since it was a case study. It can be a basis
for future studies on a better statistical criterion as well as on
more patients.
Hip bursitis (inflammation)
Hip bursitis can be characterized as the swelling of bursae. The
bursae are uid-lled sacs that cushion muscles and tendons.29
The hip is similar to the shoulder since it is also a ball-and-
socket joint. However, the hip has much more exibility in
movement as compared to the shoulder where it is attached
to the trunk. It is common that patients are not aware they
have a hip inammation since they might complain about the
pain in the anterior knee and thigh rather than the hip itself.
O3 therapy can be used to alleviate hip pain due to functional
overload, trochanteric bursitis, pain caused by initial and late
coxarthrosis, and hip tendonitis. It is also helpful to associ-
ate oxygen-O3 therapy along with prescribed exercises and a
period of rehabilitation. In a case report,27 a 54-year-old man
was treated by a cycle of 5 therapy session of O3. The dosage
consisted at a concentration of 25 µg/mL at 55 mL oxygen)
through weekly intervals. It was injected at a lateral approach
where the method of inltration was called peritrochanteric.
The patient referred difculty walking with deambulation
for approximately 50 meters and nocturnal hip pain.27 The
joint pain subsided after the rst treatment session with an
improvement in trochanteric swelling. At the end of the treat-
ment cycle daytime and nighttime pain had disappeared. By
the subsequent follow-up visit which was approximately 5
weeks later, there were no signs of bursitis. Signs of limping
stopped and the patient was able to take the stairs without
any difculty. This study demonstrates the versatility and ef-
cacy of O3 therapy when administered in small doses through
weekly intervals.
Osteoarthritis (OA) (knee)
OA is a degenerative disease that affects function and produces
pain.30 O3 inltration accelerates anabolism and produces
better vascularization on cartilage and bone. Regarding knee
osterarticular disease, there is a great variability in terms of
gas concentration of O3 as well as the side of injection. On the
knee joint, it could be either periarticular, intra articular, and
subcutaneous. Currently, there is no cure for knee OA. Because
of this there is a focus on the amelioration of the symptoms
caused by knee OA. O3 improves the range of motion (ROM)
and slows down the degenerative process. It also is able to
inhibit chondrocytes, stem cells, inammatory cytokines, nitric
oxide, and mineral metalloproteinases. The published studies
on O3 regarding the knee are limited. Riva Sanseverino31 were
the rst people to use O3 to treat the knee OA. Over the many
years, intra articular O3 injections have found to be a costless
procedure that is effective. Patients who have severe OA will
improve at about the same rate as those with low grade OA.
The pathophysiology of OA is characterized by the destruc-
tion and softening of articular cartilage along with increased
matrix degradation due to proteoglycanases and collagenases.
Activated chondrocytes and monocytes release enzymes which
by releasing TNF-α and IL-1 multiply the inammation. The
synthesis of prostaglandins increases and there is an attempt to
maintain biomechanical matrix. It is believed that the synthesis
of O3 Messengers LOPs and ROS would act in two phases
in the synovial uids. O3 would inhibit the proinammatory
cytokines such as prostaglandin E2 (PGE2) during the rst
phase. During the second phase, O3 will act over inhibitory
cytokines such as IL-10, TGF-β, and IL-4, antioxidant en-
zymes, and neoangiogenesis. These are all working together
in the process of repairing the articular joint by stimulating
broblasts, chondrocytes, and stem cells.
Carpal tunnel syndrome
Carpal tunnel syndrome is caused by a compressed nerve in
a narrow passageway on the palm side of the wrist.32 Sec-
ondary forms are associated with a variety of diseases such
as hypothyroidism, diabetes mellitus, oestrogen therapy,
rheumatoid arthritis, amyloid disease.33 The mechanism of
oxygen O3 treatment is based on three mechanisms that are
shared by the treatment of herniated disc in the spine. By
increasing trans-tissue and intra-oxygenation along with
reduced lymphatic stasis and hypoxia, there is an indirect
vessel-mediated decompression of the nerve roots. Second,
by inhibiting the release of polymorphonucleates through in-
creasing immunosuppressive cytokines and proteinase through
macrophages.34 Third, inhibiting the release of prostaglandins
and pro-inammatory bradykinins, action on the cell-mediated
inammatory response would take place.35 Oxygen-O3 therapy
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seems to guarantee improvements of symptoms after one year
compared to steroid injections. A study conducted by Zam-
bello et al.,36 showed that 90% of patients had a signicant
improvement after O3 injection. 17% had a good control of
symptoms and 70% of patients no longer had symptoms after
a one year follow up.36 However, further studies should be
conducted to see if symptoms remain or not after two years
or more to evaluate the long-term effects.
Partial tear of the supraspinatus tendon
The supraspinatus tendon is part of the rotator cuff.37 Oxygen-
O3 therapy is one of the many methods that can be used to
relieve the symptoms. In a study,38 which consisted of 40
patients, specically 26 males and 14 females whom had
shoulder pain for approximately six months. In order for
patients to be included in the study, the size of the tear of the
supraspinatus had to be less than 1.5 cm. Ultrasound guidance
is recommended since the blind inltration does not guarantee
to get properly in the shoulder joint.38 It was concluded that
the ultrasound-guided inltration of oxygen-O3 therapy proved
to be an effective treatment method in partial tears of the
supraspinatus tendon. However, it is necessary to do further
research requiring a large sample size.
Subacromial bursitis
First degree spondylolisthesis and spondylolysis-spondylosis
is a defect of part of the vertebral arch between the superior
and inferior spinal processes. Spondylolisthesis is if the defect
results in a forward shift of one of the vertebral body on one
another.39 Eighty-three percent of the 18 patients in this had a
complete recovery from pain immediately.40 The twofold ac-
tion of O3 in the perganglionic region and in the lysis points
of the neural arch or pars interarticularis region innervated by
Luschka’s recurrent nerve is an explanation for such fast pain.21
The use of the gas mixture directly next to the lysis points on
Luschka’s nerve by exploiting the well-known analgesic and
anti-inammatory effects of the oxygen-ozone mixture. The
spine is innervated by Luschka’s recurrent nerve or posterior
primary branch and vertebral plexus.41 The plexus innervates
the end plates, longitudinal ligament, vertebral bodes, and rela-
tive peridural tissues in the pars interarticularis region or the
neural arch.41 The anti-inammatory and analgesic effects of
the oxygen-O3 mixture inltrates directly proximal to the lysis
point on Luschka’s nerve.42 Prostaglandin levels and cytokine
levels are normalized with a reduction of reactive oxidant
species and an increase in superoxide dismutase production.
A eutrophizing effect occurs when subsequent inltration into
the periganglionic region takes place both adjacent to the nerve
root compressed at the level of muscle spasm and injured by
accompanying disc protrusion.43,44 A good nal outcome is
accounted due to the combined action.
Lumbar facet joint syndrome
Lumbar facet joint syndrome can be described as pain at the
joint between two vertebrae in your spine. It is a condition
which affects about 80% of people who have lower back pain.
The main mechanism of action may be considered as follows:
there is an immediate oxidation by which the proteoglycan
in the nucleus pulposus could be oxidized immediately and
the osmotic pressure is reduced.45 The volume of the nucleus
pulposus would decrease as well as necrotize, denaturize, and
atrophy. The local blood circulation would also be changed
when the osmotic pressure is reduced. The symptoms may be
improved when increasing the oxygen supply. Regarding the
anti-inammatory effect, as the vein, lymphoid tissue, and
nerve root were compressed by the annulus brosus and herni-
ated nucleus pulposus, the lymphatic backow and venous was
obstructed which was accompanied by exudation and nerve
edema. To induce an immune response, antigenic substances
such as B-lipoprotein and glycoprotein could be released that
would result in aseptic inammation and adhesion. The pain of
disc herniation could be caused by these factors. Lastly regard-
ing the analgesic effects, enzyme products and inammatory
mediators stimulate the nerve endings near ligament and on
the disc surface that causes the pain that is associated with disc
herniation. In order to attain pain relief, the strong oxidative
activity of O3 can inactivate the above inammatory mediators.
O3 injected into the middle of the disc through the conventional
posteriorlateral route had produced the desired result for small
or medium size disc herniations.22 Regarding the large disc
herniation, the symptoms were not eliminated quickly and the
efcacy was limited due to the hernia compressing the nerve
root. The efcacy of O3 therapy is poor with patients who have
large lumbar disc herniation and greatly signicant with those
who have a small or minimal disc herniation. Since the annulus
brosus was either completely or partially ruptured, it was
found that the O3 could diffuse through the tissues that were
torn surround the vertebral or spinal disc. This would cause
the hernia and nucleus pulposus to not be fully oxidized. In a
study conducted by Lu et al.,46 the treatment of large lumbar
disc herniation with percutaneous O3 injection was greatly
effective. An improvement of local ablation and eliminating
local aseptic inammation was achieved through O3 injection
in or around the hernia areas. Therefore, it was concluded
through using percutaneous O3 injection with the inner margin
of facet via the posterior-lateral was an effective method. It
is important to note that the concentration of O3 should be
acceptable in quantity and the rupture of the annulus brosus
by high intradiscal pressure should be avoided in order to
ensure efcacy. Low pressure of repeated injection of O3 was
suggested for large disc herniation. This can be accomplished
by repeatedly pushing and pulling the syringe to allow the O3
to completely oxidize and contact the nucleus pulposus. New
O3 is then injected and the residual O3 is abandoned to avoid
rupture of the annulus brosus.
Cervical disc herniation
Cervical disc herniation is wear and tear of a disc in the neck.
It is suggested that the material from the nucleus pulposus may
act as a chemical or immunologic irritant the nerve and these
mechanisms may produce an inammatory effect.47 Studies
have hypothesized that the injection of O3 induces overexpres-
sion of antioxidant enzymes which then neutralizes excessive
ROS formation. In the degenerated nucleus pulposus, the
intradiscal injection of O3 can accelerate the degradation of
proteoglycans.14 The biochemical modication of the medium
in the extraduralspace is one of the important aspects of it.48
The cause of radicular pain is A2 phopholipase independent
of a direct inammatory process or immunological response.47
A2 phospholipase is responsible for the prostaglandins and
arachidonic acid liberation. It has been shown that there are
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high levels of A2 phospholipase in herniated discs. A power-
ful stimulus to the activation of antioxidant defense is the
result of O3 injected in the peridural space of the conjugation
foramen and disc. Even in cases that had extruded cervical
disc pathology, injections were still performed and had great
results. This is most likely due to the fact that normal tissues
and the isolate fragment are separated.48
Rheumatoid arthritis
Rheumatoid arthritis is characterized as an autoimmune dis-
ease where the body’s immune system attacks the joints instead
of bacteria and viruses.49 The syndromes include hyperplasia
of synovial cells, excess synovial uid, and forming pannus
which can damage joint deformities and articular cartilage.50,51
The etiology for rheumatoid arthritis is still not understood.
The common treatments are immunologic purging, advanced
surgical treatment, and drug therapy.52 However, O3 therapy is
a new treatment in treating rheumatoid arthritis can overcome
these limitations at a certain level. The therapeutic mechanism
of O3 still remains unclear. Previous research has showed
that O3 can reduce the activity of TNF-α in the inammatory
tissues and suppress synovial hyperplasia and joint swell in
rheumatoid arthritis in rats.53,54 Therefore, a study was con-
ducted to treat bovine collagen II-induced RA in rats with
intraarticular injection of O3 at various concentrations.55 Rats
were injected with complete Fruend’s adjuvant bovine col-
lagen II that successful established a rat model of rheumatoid
arthritis.55 In the O3 treated groups, the optimal concentration
for treating rheumatoid arthritis was 40 µg/mL.55 They also had
higher TNF-receptor (TNF-R)1 indicating that O3 can reduce
synovium injury in rats with RA and lower synovial TNF-α
and TNF-R2 levels.55 A plausible mechanism is the reduction
in TNF-R1 and rheumatoid arthritis TNF-a levels and increase
the level of TNF-R1 which increase synovial cell apoptosis
and preventing synovial cell proliferation.55
Systemic sclerosis
Systemic sclerosis is a chronic tissue disease characterized by
vascular abnormalities in the joints, internal organs, and bro-
sis.56 The etiology and clinical manifestations of scleroderma
are still not understood; this is why it is difcult to treat sys-
temic sclerosis.56 The inammatory processes can be limited by
O3’s potential in reducing the proliferation of neutrophils and
mastocytes, increasing concentration of prostacyclin 6-keto-
prostaglandin F1α (6-keto-PGF1α), impeding the release of
acute phase proteins, and decreasing the concentration of
prostacyclin (PGF)2α resulting from the oxygen radicals on
arachidonic acid.57 The results from this study have proved
to slow down the progression of the illness by limiting the
activation of the immune system. It had also increased the
movability of interphalanx joints and decreased the thickness
of the skin.57 O3 is able to penetrate the epidermis water-fat
barrier and also has a good solubility in serum which is why
it has a good effect on the skin.57 The vasodilating effect of O3
allows for the decrease of skin score index, decrease of arterial
blood pressure, increase in angle of interphalangeal joints all
through the synthesis of nitric oxide synthase.57
Fibromyalgia
Fibromyalgia is seen as a rheumatic disease which means that
it causes myofascial pain or soft tissue pain.58 The mechanism
of O3 is as follows. After the O3comes into contact with the
blood, it immediately reacts with various reducing molecules
such as antioxidizing agents, unsaturated fatty acids containing
double bonds to produce reactive oxygen species. Both lipid
peroxidation products and hydrogen peroxide are generated,
when O3 reacts with polyunsaturated fatty acid (PUFA).59
Enzymatic antioxidant systems such as aldehyde dehydro-
genase and glutathione-transferase neutralize the toxicity
of both molecules (LP and hydrogen peroxide). They act as
secondary messengers which stimulate further generation of
antioxidant enzymes.60 This can be done if O3 is administered
in quantities that are able to achieve a therapeutic effect which
can protect against radicals and is nontoxic. A case which a
45-year-old woman was administered oxygen-O3 therapy
biweekly sessions equating to a total of 12 sessions. Due to a
lowering of painful symptoms, the patients experience a sense
of well-being. An improvement in the asthenia was seen due to
a greater oxygenation of tissues because of O3. There were no
side effects seen in this case. The limitation from this study is
the small number of patients in which it was conducted. It was
found that O3 glycolysis was sped up through the activation of
the mitochondrial respiratory chain.61,62 The O3 mixture will
cause an increase in oxygenation level due to the increased
efciency of the antioxidant enzyme system, enhance sero-
tonin production, and microcirculation. The production of
endorphins was enhanced by the motor plate. So patients who
had bromyalgia had improved their daily activities by 40%
and sleeping disorders by 6%.63
Muscle oxygenation
The role of O3 therapy was observed for hypoxic tissues, those
in which tissues were below-normal level of an adequate oxy-
gen supply.64 A study has demonstrated that O3 therapy can
change the level of oxygenation in resting muscles by measur-
ing directly the pressure of oxygen.64 Through autohemotrans-
fusion, O3 therapy avoids lung toxicity from oxidative stress.
The effects of O3 are mediated by rapid oxidation of blood
substances. Hydrogen peroxide and peroxidated lipoproteins
both are reactive oxygen species that can activate the hexose
monophosphate shunt. Charge modication is done by the in-
crease of malonyl aldehyde and lipid peroxidation as well as an
improvement of blood rheology and exibility of erythrocyte
membrane. The collaboration of nitric oxide, adenosine, and
prostaglandins can decrease vascular resistance. It is hypoth-
esized that this will lead to blood ow redistribution. This is
supported by the data collected in the study which shows the
correlation between the change in pressure of oxygen post-
ozone therapy and the initial oxygenation. Another possible
mechanism to explain the results of this experiment, is the
increase in production of 2,3-diphosphoglycerate in erythro-
cytes and lipid peroxidation of red blood cell membranes can
be achieved with the activation of the hexose monophosphate
shunt.65 These would both cause a shift to the right in the
oxyhemoglobin dissociation curve ultimately leading to an
increase of release of oxygen to the tissues.65
Spinal muscle disorder (horse)
The harmonious movement of the spine and balance are the
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result of the muscles running along the spine to the dock of
the tail. Muscle fatigue is caused by soft tissue spinal lesions.
Impaired performance in athletic horses is mainly caused by
changes in the thoracolumbar spine. One of the many patho-
logic changes affecting the thoracolumbar spine is soft tissue
spinal lesions. The muscles may suffer varying degrees of
inammation after intense muscular stress. In the study con-
ducted, all four horses had a positive response to O3 therapy.66
They were all able to increase their trotting speed due to the
stiffness that was relieved and increase in posterior muscle
chain thrust. The mechanism of action of O3 is described as
the O3 coming in contact with the blood on different targets.
Since O3 is very active it reacts when it comes in to contact
with blood or any biological uid. O3 rst reacts with polyun-
saturated fatty acids then with proteins, antioxidants (ascorbic
acid and glutathione). When O3 reacts with bio molecules, it
produces a molecule of ROS which is hydrogen peroxide and
two molecules of lipid oxidation products. The ROS activates
the pentose phosphate pathway. The lipid oxidation products
that are produced as 4-hydroxynonenal and malonaldehyde.67
Since they are toxic, they undergo a dilution in the circula-
tion and get metabolized in the blood circulation. Overall, the
benecial effects seen by O3 therapy is the increase in avail-
ability and delivery of oxygen, adenosine triphosphate (ATP),
and glucose within ischemic tissues, enhances implantation of
bone marrow stem cells at the site of lesion which can provide
neovascularization, tissue regeneration, and angiogenesis.
Ballardini66 did not notice any short or long-term effects when
administering different treatment cycles to the same horse; he
always noticed a positive response from the horse.
Spinal pain
About 80% of the world’s population has a symptom of low
back pain.68 In general, the pain one suffers from a herniated
disc is caused from inammation and not compression. The
use of O3 therapy is recommended to treat back pain before
doing any surgical procedures. There are two techniques one
can attempt: direct approach and the indirect approach. O3
acting as a chemical reactant by needle insertion refers to the
indirect approach. Whereas, the direct approach is done by
direct insufation of the oxygen-O3 mixture of a concentration
at approximately 30 µg/mL and preceded by needle insertion
in the pathologic intersomatic space. Eighty percent of 63,000
patients have shown good outcomes conrmed by magnetic
resonance imaging (MRI) controls and computed tomogra-
phy.48,69 In the future, it is essential to conduct more studies
to assess the role of variables such as place of needle, needle
type, O3 concentration, and oxygen amount. The mechanism
of action underlying O3 therapy for the direct method is: O3
reacts with biomolecules when dissolved in interstitial water,
which then results in the formation of reactive oxygen spe-
cies such as hydrogen peroxide and hydroxyl radicals.70,71
The matrix degenerates with disappearance of the herniated
material, when ROS reacts with proteoglycans of the nucleus
pulposus,72 thusleading to a lower of sensitivity of axons.
Alternatively, nociceptors can be stimulated when algesic
endogenous substances released during perineural ischemia.
The indirect approach consists of one to four injection of 5–10
mL of O3. The disappearance of pain because of the complex
series and chemical and neurological reactions have dened
it as a chemical acupuncture. The O3 concentration must be
between 18–25 µg/mL.73 If it is higher than 20 µg/mL, it can
be too painful, and if it is too low, then it won’t be effective.
Therefore, it is essential to maintain the right balance since it
can cause risky vasovagal reex and lipothymia during initial
treatments. Contrarily, the pain threshold rises after ve to
seven treatments therefore, the concentration of O3 increases,
but must not exceed 30 µg/mL. The inltration of O3 therapy
uses the paravertebral muscles as a route. Regarding the indi-
rect method, the mechanism of action underlying O3 therapy is
described as O3 reacting with PUFA, LOPs, and anti-oxidants.
The nal therapeutic effect is achieved with these compounds
stimulating local C-nociceptors. Altogether, it is concluded
that injection of O3 either into the paravertebral muscles or
intradiscally has indicated long-term pain relief.16,74
Lumbar spinal stenosis (LSS)
LSS can be characterized as the narrowing of the spinal ca-
nal of the lumbar area.75 The three main symptoms that LSS
gives rise to are radicular pain or discomfort, low back pain,
and neurological intermittent claudication.O3 therapy blocks
phospholipase A2 which is the same enzyme that epidural
steroid injections target.76-78 Therefore, O3 can serve as a better
substitute steroid since it has the same mechanism of action
while being a much safer drug. The neurological pain in LSS
can be improved by the microcirculation that O3 induces.79
In a study conducted by Baeza-Noci,76 patients with spinal
stenosis underwent O3 therapy for 10 biweekly sessions along
with 5 weekly sessions. Each injection of O3 (10 mL) had a
concentration of 20 μg/mL. After 1 year, from the baseline,
74% of patients improved with excellent results.76
Complications of O3 therapy in musculoskeletal disorders
The reactivity of O3 gives rise to a cascade of reactions such
as the lipid ozonation products acting as signal transducer
molecules, peroxidation of lipids leading to changes in mem-
brane permeability.80 Endogenous mediators of inammation
are released by the activation of lipases through which LOP
activates the lipases.81,82 It is the O3 which reacts with unsatu-
rated fatty acids such as in the pulmonary cell bilayers and
lung lining uid. Enzyme inactivation occurs when there is a
loss of functional groups in enzymes. Cell death or cell injury
may occur from these reactions. Hazardous effects on lung
alveoli can occur with the combination of nitrogen dioxide
(NO2) and O3 that are in photochemical smog. These effects
can be prevented by free radical scavengers such as vitamin
E, C or dietary antioxidants. In an in vitro study, peroxides
were found to be formed by the presence of O3 and oxidized
arachidonic acid.83 The activity of prostaglandin endoperoxides
are comprimable to that of arachidonic acid peroxides. The
aggregation of human platelets in platelet-rich plasma was
seen with arachidonic acid peroxides. While, the presence of
vitamin E and indomethacin, presented no signs of aggrega-
tion of human platelets in platelet-rich plasma.83 Therefore,
this suggests that they can treat O3 toxicity.
cOncLUsIOn
O3 therapy is becoming an effective treatment option for
musculoskeletal disorders as it promotes tissue hyperoxygen-
ation as well as treating painful syndromes affecting muscles,
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Seyam et al. / Med Gas Res www.medgasres.com
tendons, and joints. Though O3 has indicated great success in
most indications mentioned in this review, there still needs
to be further research conducted to determine its activity for
treatment of plantar fasciitis, costochondritis, and myofascial
syndrome. In order to prevent the common side effects that
O3 therapy causes, it is essential to continue researching the
utility of O3 therapy in all indications.
Acknowledgments
The authors are thankful to Drs. Kelly Warren, Todd Miller, and
Peter Brink (Department of Physiology and Biophysics, Stony
Brook University School of Medicine, Stony Brook, NY, USA) for
departmental support, as well as Mrs. Wendy Isser and Ms. Grace
Garey (Northport VA Medical Center Library, Northport, NY, USA)
for literature retrieval.
Author contributions
OS designed, organized, and wrote the review article; designed the
outline; solved queries related to scientic publications from the
journals. NLS performed Medline searches, aided in writing the
review article and critiqued the literature. IR revised the article to
add logical reasoning and corrected the literature. JG critiqued and
applied logical reasoning to the literature. WJ critiqued and applied
logical reasoning to the literature. SAK formulated clinical concepts,
reviewed the article, and corrected the reference. All authors have read
and approved the manuscript provided.
Conflicts of interest
The authors have no conicts of interests to declare.
Financial support
None.
Copyright license agreement
The Copyright License Agreement has been signed by all authors
before publication.
Plagiarism check
Checked twice by iThenticate.
Peer review
Externally peer reviewed.
Open access statement
This is an open access journal, and articles are distributed under
the terms of the Creative Commons Attribution-NonCommercial-
ShareAlike 4.0 License, which allows others to remix, tweak, and
build upon the work non-commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
Open peer reviewer
Nemoto Edwin, University of New Mexico Health Sciences Center,
USA.
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Received: 2018-05-30
Accepted: 2018-08-09
C-Editor: Yang LJ, Zhao M; S-Editor: Yu J;
L-Editor: Wang L;
T-Editor: Jia Y
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