Ozone Therapy for Athletes

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Recently, new ways to improve sports performance and aid recovery have sparked an interest in ozone therapy. Ozone, a naturally occurring form of oxygen containing three oxygen atoms, has gained recognition for its potential benefits. 

Ozone therapy is hardly a new technology–it has been in use for over 150 years. During World War I, ozone was used topically to treat wounds and help prevent infection and inflammation. To this day, it continues to be used for various conditions despite its controversial image.

Athletes and other fitness enthusiasts are turning to ozone therapy as a complementary method to other performance and recovery strategies. As a highly reactive molecule, it works by reacting with molecules in the human body, generating byproducts that trigger physiologic responses. These could result in anti-inflammatory, immune-boosting, and oxygenating properties that support performance, reduce fatigue, and support the body’s ability to repair and regenerate.

Clinical trials in athletes, although limited, have shown that ozone therapy enhances athletic performance. Therefore, using ozone therapy involves navigating anti-doping rules. However, integration into sports medicine and performance enhancement programs holds promise for athletes seeking a holistic approach to athletic excellence. In this article, we break down why.

Is Ozone Therapy Banned for Athletes?

Athletes in World Anti-Doping Agency (WADA)-regulated sports need to be aware of regulations surrounding sports medicine treatments. Ozone therapy is no exception. The WADA has provided guidance specific to ozone therapy. It highlights that ozone itself is not a prohibited substance, but certain routes of administration are. 

WADA has banned any situation where blood is removed and reintroduced to the body. Therefore, autohemotherapy is not allowed. Any injections of allowed substances also have to be less than 100 mL within a 12-hour period. However, other delivery routes, such as rectal insufflation, are permitted. 

Ozone therapy should be administered under the guidance of those who are familiar with WADA regulations. This helps ensure that it is given correctly, and without introducing another banned substance. 

How Ozone Therapy Works in the Body for Athletic Benefits

Ozone reacts with various molecules in the body, creating molecules that deliver health benefits. When it’s high in the atmosphere, ozone is present at high enough doses to be toxic when inhaled. While you certainly could generate a detrimental dose of ozone into the body, it's primarily breathing ozone that is toxic. Our lungs don't have the antioxidant defenses capable of handling ozone. Whereas, the same dose could be administered into the blood without the detrimental effect due to the antioxidant capacity. 

Ozone exposure without inhalation at low doses, such as with ozone therapy, is very safe. The small doses of ozone trigger beneficial pathways in the body. These may include:

  1. Some of the ozone breaks down into oxygen gas in the body. 
  2. Some of the ozone reacts with lipids, proteins, cellular components, and other molecules in the body, creating byproducts that produce its therapeutic effects.
  3. The small amount of oxidative stress introduced by ozone turns on mechanisms involved in antioxidant defense, tissue repair, stem cell, immune function, and anti-aging

Ozone Therapy Routes of Administration in Sports Medicine

Before we dive into how ozone therapy delivers athletic benefits, it is important to understand that ozone can be administered in many ways. The route used depends on the effect you are hoping to achieve and what’s legal in your sport:

  • Ozone injection: Small amounts of ozone gas and oxygen can be injected locally into specific body areas, like joints or tissues. This method requires the skills of an experienced clinician. This method is often used when ozone is needed locally, mainly in musculoskeletal conditions like joint pain, arthritis, or soft tissue injuries. This method aims to stimulate the body’s anti-inflammatory and healing processes around the injected areas, especially for chronic injuries that don’t fully heal.
  • Ozonated water and oil: Ozone can be bubbled through water or oil, which can then be either ingested or used topically. Topical application of ozone water or oil is often used for wound care to promote healing or for other skin conditions.
  • Ozone sauna or ozone bagging: Ozone can also be introduced in a sauna environment, where the skin is exposed to ozone and subsequently ozonated byproducts can be absorbed through the skin. Often this method is used for detoxification or skin conditions.
  • Ozone insufflation: This method involves administering ozone gas into a body cavity, where ozone and ozonated byproducts can be absorbed through the blood vessels and mucous membranes. There are multiple different routes, including rectal, vaginal, and ear. These methods can deliver both local and systemic (throughout the body) benefits. 
  • Ozone autohemotherapy or intravenous ozone: This method involves removing a small amount of blood from the body, mixing it with ozone, and then reintroducing the blood back into the vein. Often, this method is used to stimulate the immune system, improve oxygenation, and reduce inflammation. This method is most used for conditions that have systemic effects, like chronic infections or immune disorders. Currently, ozone autohemotherapy is banned under the World Anti-Doping Agency, unless the athlete has a therapeutic exemption. 

The choice of administration route depends on your specific health objectives and the condition you want addressed. It is always best to consult with a healthcare provider to determine which method might benefit you.

How Ozone Therapy Benefits Athletes

Ozone therapy has become a popular choice for athletes because many of them experience benefits anecdotally. While few studies have looked at specific effects of ozone in sports, results from studies in other conditions can be deduced to apply to sports performance.

1) Increased oxygen metabolism & utilization

The ability to oxygenate tissues is a key determinant in sports performance, recovery, and tissue healing as oxygen is essential for healthy mitochondrial function. Oxygenation is a crucial factor for athletic performance and recovery. Oxygen and oxidative therapy like ozone do this by optimizing cellular respiration and energy production processes in the body.

Ozone therapy, both from autohemotherapy and an ozone sauna, might help athletes improve their endurance by improving tissue oxygenation and metabolism. 

Ozone therapy can also trigger the production of protective antioxidant enzymes and vasodilators to promote overall cell health. As a vasodilator, it can improve blood flow, which also enhances oxygen and nutrient delivery. With autohemotherapy, ozone reacts with the cell membrane of red blood cells, thinning the blood. 

One study, involving eight elite amateur athletes, looked at ozone autohemotherapy to see how well it could enhance oxygen delivery to body tissues. Through periodic tests that measured the anaerobic threshold, six athletes showed clear improvement. This suggested that ozone autohemotherapy may enhance oxygen delivery to muscles and peripheral tissues.

Caption: Effects of ozone autohemotherapy on anaerobic threshold based on Conconi test. Left panel: initial anaerobic threshold, middle: the athlete’s average anaerobic threshold in response to training. Right panel: the improvement in anaerobic threshold (at lower heart rate and speed) in response to ozone therapy. Adapted from Gjonovic et al (2006).

In another study, 26 subjects with blood flow disorders received ozone autohemotherapy to see if it could modify muscle oxygenation parameters. They received treatments every other day for a week. The study found that ozone could modify oxygenation in resting muscles, especially in those with lower levels of oxygen, making it potentially useful in athletes. 

Another clinical trial enrolled six healthy male volunteers who received one 20-minute session in an ozone-oxygen steam sauna, compared to a steam sauna alone. At 0, 0.5, and 1.0 hours after the ozone session, the participants had elevated partial pressure of oxygen in their venous blood. After the ozone treatments for up to 0.5 hours, participants also had increased blood markers of oxidative stress and immune system activation.

While no clinical studies are using rectal insufflation in athletes, studies in hypoxic patients suggest that rectal insufflation can improve tissue oxygenation throughout the body.

2) Mitochondrial health and energy production

Mitochondrial function is crucial for exercise performance and recovery, even in glycolytic or power sports.

Ozone and some of its fatty acid peroxidation products activate the Kreb’s cycle, boosting the production of ATP and thus energy. In the blood, ozone can enhance the breakdown of glucose in red blood cells for energy.

In a clinical trial involving six healthy patients, high-dose autohemotherapy significantly boosted the bioenergetic health index, a measure of mitochondrial function.

3) Red blood cell health and function

Ozone might also impact how red blood cells (RBCs), the cells that transport oxygen around your body, function. In a rabbit study, researchers used rectal insufflation to deliver ozone through the rectum and observed its effects on RBCs. After 15 days of treatment, the RBCs had multiple notable changes – improved flexibility, less aggregation, and better stress resilience. 

While this study was done in animals, the results might have a few benefits for athletes:

  • Improved cellular flexibility: When RBCs become more flexible, blood flow into small blood vessels might improve. For athletes, this might help with oxygen delivery to muscles, thus enhancing performance, recovery, and training response.
  • Less aggregation: By preventing RBCs from clumping together, blood can flow freely through the vessels and impact performance in the same way better flexibility might. Decreased aggregation might also reduce the risk of blood clots.
  • Less fragility: This means that RBCs exposed to ozone were less likely to break from stress. Having more blood cells that survive longer means better oxygen delivery and physical performance.

It is important to note that in this study applied the treatment for a longer duration (21 and 36 days), some of these changes eventually returned to baseline.

Ozone therapy also enhances energy production in red blood cells causing their hemoglobin to dissociate from oxygen more readily. This may imply better oxygenation of target tissues such as muscles. 

3) Endurance & stamina

Because ozone therapy improves oxygenation, mitochondrial health, and red blood cell function, it can improve endurance, stamina, and resilience.

In one study on athletic performance in football players from the Turkish National League, ozone therapy showed remarkable benefits. Thirty male football players were initially assessed using an Astrand Treadmill Test. The players who received ozone autohemotherapy twice a week for five weeks had significant improvement in performance compared to those who didn’t get the therapy.   

The players had an impressive 28% increase in VO2 max (a measure of aerobic fitness, the maximum amount of oxygen the body can absorb and use) and a 20% increase in max running time. In contrast, the control group only had a 12% increase in VO2 max and a 6% increase in max running time. These findings suggest that ozone therapy could be a highly effective strategy for enhancing athletic performance, particularly beneficial before critical seasons or tournaments.

Caption: Ozone therapy boosted max running time by 20% (top panel) and VO2max by 28% (bottom panel). Adapted from Turan MT (2021).

4) Immune system support

Strenuous training can temporarily increase oxidative stress and inflammation, along with cortisol. All of these can weaken the immune system. So, ozone therapy’s immune-boosting effects can be particularly beneficial both in terms of preventing illnesses and enhancing recovery from training.

Ozone can help with the immune system in two ways

  • As oxidants, ozone and ozonated byproducts can disrupt the structures of bacteria, viruses, fungi, yeast, and protozoa. This interferes with their reproduction and allows the body to get rid of them.
  • Your immune system naturally uses oxidative species as a weapon against some pathogens, and as signals to communicate between cells. At specific low concentrations, ozone and ozonated byproducts provide signals that supercharge the immune system. These signals include interferon, tumor necrosis factor, and interleukin-2. 

5) Reduced inflammation and better healing

Inflammation plays a dual role in sports–you need inflammation to generate many training responses, but too much inflammation can hinder recovery and reduce well-being. Intense and long training sessions can also generate too much inflammation which makes recovery and injury healing difficult.  

Ozone supports your body to do the right thing with inflammation. It does not suppress the inflammation you need for training responses, but it balances out excess or chronic inflammation that hinders healing. When acute inflammation is needed, such as during acute injuries, shortly after a training session, or during infections, ozone stimulates the inflammation. 

Ozone also seems to improve epithelialization, collagen deposition, and cell proliferation. This is why ozone injection into soft tissues and joints can promote recovery from injury. More importantly, ozone therapy can also help normalize pain neurons, which may induce pain relief.

6) Cellular antioxidant protection

Studies show ozone can combat the effects of oxidative stress. As we age, this becomes even more important. One animal study found these effects in aging mice.  Researchers showed ozone can reduce oxidation markers and improve glutathione status. The ozonated byproducts in your blood boost the production of antioxidant enzymes, acting as superheroes that promote cellular health and protection.

Ozone therapy triggers the production of many antioxidant enzymes, including:

  • Glutathione peroxidase
  • Catalase
  • Superoxide dismutase 
  • HO-1

These enzymes neutralize free radicals, protecting cells and tissues from damage. For athletes in intense training, this can be a game-changer for recovery, aging, immune health, energy, and many other aspects of health.

7) Recovery

Ozone therapy has the potential to play a helpful role in post-exercise recovery, which requires the ability to balance oxidative stress and inflammation, and mitochondrial function. By stimulating mitochondrial ATP production, ozone therapy could support a faster recovery process. This is especially helpful for athletes undergoing intense training or competition.

By adjusting oxidative stress and cytokine levels, ozone can also mitigate inflammation and alleviate exercise-induced muscle soreness. By recovering more quickly after strenuous exercise, athletes can continue to perform at a high level. It's like giving the body a boost to recover more efficiently after pushing its limits during physical activity.

8) Injury and pain management

Ozone injections are often used to treat injuries and degeneration in high-level sports. To treat the problem, ozone is injected directly into the affected area, such as joints, muscles, or ligaments. The rationale behind it in the context of sports medicine lies in its ability to stimulate a healing response. 

Ozone and ozone byproducts help with:

  • Improved tissue oxygenation and blood flow. Joint injuries often heal poorly and slowly because cartilage, tendons, and ligaments receive less blood flow.
  • Stimulating local mitochondrial function, which can reignite stagnant healing processes 
  • Normalizing inflammation and oxidative stress
  • Activating stem cells
  • Turning on tissue repair genes such as collagen production genes

Ozone therapy is often a lower-risk and better-tolerated treatment than surgery and certain medications. In one study, 52 herniated disc patients who had not responded to conservative treatments received intramuscular ozone injections alongside steroid and local anesthetic. When followed up, they had lower pain intensity and disability scores, and all reported statistically-significant improvements. 

In a study of 238 knee pain subjects, ozone injections provided faster and superior short-term pain relief compared to other types of injections, including hyaluronic acid and platelet-rich plasma. Those who received ozone reported improvements in pain, stiffness, and function after two months indicating that this treatment is valuable for short-term knee pain. 

In hamstring injuries, ozone was effective and well-tolerated. The researchers also noted that there was increased blood flow to the injured muscle, and subjects had less pain and performed better in the toe-touch test. 

Summary of Ozone for Injury & Overuse 

Study Condition Intervention Subjects Parameters Outcomes
Randomized Controlled Trial Acute low back pain from lumbar disc herniation Intramuscular-paravertebral ozone injections 60 Pain reduction, disability, analgesic use Significant difference in pain reduction and disability in ozone group
Observational/Retrospective Chronic back pain from disc herniation Intramuscular-paravertebral ozone injections compared to posture rehabilitation or both Not specified Pain severity (using VAS) Lower back severity in ozone group
Randomized Controlled Trial Lumbar disc herniation from trauma Low, medium, and high concentrations of ozone 80 CT disc volume reduction, serum IL-6 levels, SOD activity 40 ug/mL of ozone showed optimal anti-inflammatory efficacy
Retrospective Low back pain from lumbar disc herniation Paravertebral ozone injections 122 Pain (VAS), disability index scores (ODI) Significant improvement in VAS and ODI scores
Randomized Controlled Trial Lower back pain Paravertebral ozone injections 109 Changes in pain and back disability 79% had significant reduction in pain and back disability
Case Reports Severe, acute lower back pain with disc herniation Intramuscular-paravertebral ozone injections 1 Pain reduction, improvements in quality of life scales Reduction in pain, improvement in quality of life scales
Case Reports Acute low back pain from facet joint syndrome Percutaneous ozone injections (ultrasound guided) and aquatic exercise program 1 Pain reduction Reduced pain maintained at 6 month follow up
Systematic Review Lower back pain from disc herniation Percutaneous ozone injections Not specified Pain reduction Ozone appears to have positive results
Systematic Review Lower back pain with disc herniation Percutaneous injections of ozone Not specified Pain reduction, safety Consistent pain reduction with few adverse events
Systematic Review Lower back pain Intramuscular-paravertebral injections of ozone Not specified Efficacy and adverse events Effective and safe for pain
Randomized Controlled Trial Knee osteoarthritis Intra-articular ozone, hyalurnic acid, and combined therapy Not specified Pain reduction and disability scores Significant reduction in pain and disability, all groups had improvements
Randomized Controlled Trial Knee osteoarthritis Intra-articular ozone vs hyaluronic acid injections 42 Pain reduction Comparable pain reduction in both groups, hyaluronic acid group had significantly lower pain at 6 month follow up
Randomized Controlled Trial Knee osteoarthritis Ultrasound-guided ozone vs corticosteroid injections 62 Improvement in knee pain Both treatments were effective, ozone effects lasted longer
Randomized Controlled Trial Knee osteoarthritis Ozone compared to NSAIDs and supplements 76 Pain reduction Greater pain reduction with ozone therapy
Randomized Controlled Trial Knee osteoarthritis Intra-articular ozone compared to placebo 98 Pain reduction, quality of life, ambulation Ozone more effective than placebo in improving pain, ambulation, and quality of life
Systematic Review and Meta-analysis Knee osteoarthritis Intra-articular ozone vs hyaluronic acid injections, and placebo 428 Pain reduction Ozone superior to placebo, not statistically significant to other treatments
Meta-analysis Knee osteoarthritis Intra-articular ozone therapy Not specified Knee pain reduction Ozone had short term effects for reducing pain
Meta-analysis Knee osteoarthritis Intra-articular ozone therapy Not specified Knee pain reduction Short term effects for reducing pain
Systematic Review Knee osteoarthritis Intra-articular ozone therapy 858 Pain reduction and safety Ozone was safe and encouraging results for being effective at managing pain
Other Pain
Observational Cervicobrachial pain Intramuscular-paravertebral ozone injections 168 Pain reduction Significant pain reduction at follow up
Comparative Chronic lateral epicondylitis (Tennis Elbow) Ozone vs corticosteroid injections 80 Pain reduction Ozone more effective in pain reduction at 3,6, and 9 months

9) Mental health

Let’s not forget about mental health and how it affects athletic performance. Ozone therapy may help with stress, anxiety, and mood changes.

A study exploring ozone therapy for fibromyalgia found improvements in symptoms, especially during the first four weeks of treatment. Almost half of the subjects felt better both physically and mentally after ozone was given via rectal insufflation. This was one of the first studies that showed impacts beyond physical improvements, to mental health as well. 

Another clinical trial of patients with hard-to-treat symptoms of severe diseases found significant improvements in anxiety and depression scores. 

The researchers think that ozone therapy normalizes oxidative stress, nitric oxide levels, and cytokine balance. By regulating these factors, ozone therapy might help with pain, fatigue, and mood disorders. It takes a holistic approach to mental well-being, which is especially helpful for athletes. 

How Frequently Should Ozone be Given to Enhance Athletic Performance?

Ozone therapy works by generating a small amount of stress to trigger beneficial responses, which means that too frequent application can lead to adaptations.

In a clinical trial in Turkish football league players that detected a significant boost in VO2max, athletes received 20-30 mcg/mL autohemotherapy twice a week for five weeks. Another trial that raised the anaerobic threshold applied 30 gamma/mL every three days for up to four applications. 

The frequency of ozone treatment for athletes can vary depending on individual health status, goals, and response to ozone therapy. Your provider will consider your medical history, sports goals, and other factors to plan your treatment. In general, you will need more than one treatment and multiple sessions to optimize your results. 

Is Ozone Therapy Safe?

For most people, ozone is safe and well-tolerated. Mild and temporary side effects can occur, with bloating being the most common. The side effects vary due to different factors, mainly the route that is given through:

  • Autohemotherapy: Autohemotherapy can cause temporary dizziness, fatigue, or bruising in some people. It is essential to use sterile procedures to cut the risk of infection. 
  • Insufflation: Rectal insufflation may cause temporary discomfort or gas. A feeling of fullness can be associated with vaginal insufflation. In rare cases, irritation or inflammation of mucous membranes may occur. Proper hygiene and technique are crucial to prevent infection.
  • Ozonated water or oil: Drinking ozonated water is generally considered safe when consumed in moderation. However, excessive intake may lead to stomach discomfort or nausea. Topical application of ozonated water or oil may cause skin irritation in sensitive individuals.
  • Ozone sauna: Using an ozone sauna makes you sweat, which can make you dehydrated. So, it is important to drink enough water. Some individuals may experience heat-related symptoms like dizziness and fatigue. Skin irritation can also occur in rare cases. 
  • Ozone injection: Ozone injected into a specific area might cause temporary discomfort. Infection is a potential risk if proper sterile techniques are not followed. Rarely, individuals might experience allergic reactions. 

Another thing to consider is the dose. In high concentrations, ozone can be toxic, making the administered dose critical. Providers offering ozone therapy must follow established guidelines and protocols to ensure safety. Improper administration or unsupervised use can lead to negative effects. 

Finally, some people may experience a Herxheimer reaction. This is an adverse response that can occur during the initial phases of some treatments, particularly when some bacteria, parasites, or fungi die after ozone exposure. Because ozone has potential anti-microbial and immune-activating effects, this can be a risk. The good news is that these reactions are usually transient and self-limiting. This is also why most people should start ozone therapy at a very low dose and frequency, and gradually increase the dose and frequency over time. 

Who Should Avoid Ozone Therapy?

Certain people should avoid or be cautious with ozone therapy due to potential risks and contraindications. Here are some general guidelines: 

  • Pregnancy: Ozone is generally not recommended in this population. This is due to concerns over potential effects on fetal development.
  • Glucose-6-Phosphate Dehydrogenase Deficiency: This genetic condition affects red blood cells. Those who have it might be at increased risk for red blood cell destruction when exposed to ozone therapy.
  • Bleeding Disorders: Ozone therapy has anticoagulant effects. So, it is recommended that anyone with bleeding disorders or on blood thinners should avoid it. 
  • Autoimmune Disorders: Ozone therapy can stimulate the immune system. This might be a problem if you have an underlying autoimmune disorder. Immune stimulation may exacerbate the condition.  
  • History of Seizures: In some people with a history of epilepsy, ozone might trigger seizures. Ozone therapy should be approached with caution in those with these conditions.  
  • Respiratory Conditions: Ozone can irritate the respiratory tract. This can be a problem for those with asthma or COPD. However, this only applies if ozone is being administered via inhalation, which is not commonly done.
  • Allergy or Sensitivity: some people may be allergic or sensitive to ozone. Those with a history of allergy or chemical sensitivities should be extra cautious with ozone exposure.
  • Children: Ozone is not well studied in children, and the potential risks are not fully understood. Therefore, it is best avoided in this population until more research is done.

Before starting ozone therapy, it is crucial to consult with a healthcare provider knowledgeable in the field to ensure it is safe for you. They can look at your medical history and specific health concerns to ensure that ozone therapy is appropriate.

Final Notes

In conclusion, ozone therapy’s integration into sports medicine is an evolving field with numerous potential benefits for athletes. Particularly, ozone might improve oxygen delivery, reduce inflammation, and enhance physiological resilience. This therapy offers an innovative strategy to enhance performance. Plus, it can be administered in various ways, allowing for personalized approaches. 

Yet, individual considerations are important before incorporating ozone therapy into an athlete’s regimen. Each person can respond differently to ozone therapy depending on overall health, fitness level, and the specific demands of their sport.

Athletes should always collaborate with their healthcare providers who know about ozone. This can ensure it is safe and effective for their unique needs. Personalized approaches, considering individual athlete goals and health conditions, are crucial. 

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