The Arabic board of medical specializations

Anesthesia & intensive care

Evaluation of the analgesic

effect of five intra-articular
ozone injections of knee
osteoarthritis
A thesis Submitted to the Scientific Council of
Anesthesia and Intensive Care as a partial fulfillment
of the requirements for the degree of the fellowship of
the Arab Board for Medical Specializations in
Anesthesia and Intensive Care

Prepared by

Dr. Ali Saadoon Hashim

M.B.Ch.B.

Trainee in the Arab board program of anesthesia & intensive care

Under supervision of

Dr. Iyad Abbas Salman

M.B.Ch.B. / DA/ F.I.C.M.S Anes. +IC/ CABA& IC

2013
 ‫ﺑﺴﻢ ﺍﷲ ﺍﻟﺮﲪﻦ ﺍﻟﺮﺣﻴﻢ‬

‫ﻭﻣﺎ ﺍﻭﺗﻴﺘﻢ ﻣﻦ ﺍﻟﻌﻠﻢ ﺍﻻ ﻗﻠﻴﻼ‬

‫ﺻﺪﻕ ﺍﷲ ﺍﻟﻌﻈﻴﻢ‬

‫ﺍﻻﺳﺮﺍء ‪85‬‬
 Dedication

To my parents & my wife, for their patience & support

Dr. Ali S. Hashim

I
 Acknowledgement

To my Professorial supervisor; I am precious for your

time and your wonderful efforts, and to all the marvelous
people who helped me to complete this research, thank
you very much.

II
 Supervisor Certification

I certify that all the work presented in this thesis was

prepared by: Dr. Ali Saadoon Hashim under my
supervision in the department of Anesthesia of Medical
City Complex, Baghdad. Iraq.

Dr. Iyad Abbas Salman

M.B.Ch.B/D.A/F.I.C.M.S/C.A.B.A&I.C

III
 Examining Committee Certification
We, the examining committee , after reading this thesis
and examining the candidate Dr. Ali Saadoon Hashim, in
its content, find that it meet the standards and
requirements as a thesis in partial fulfillment for the
degree of fellowship of the Arab board of medical
specialization in anesthesia & intensive care.

Dr. Hassan Sarhan Haider

M.B.Ch.B / DA / FICMS A&IC
Chairman of the Arab board scientific council
Of anesthesia and intensive care

Chairman

Dr. Alaa Hussein Ali Dr. Ghison Ibrahim Kadhim

Consultant Anesthetists Senior Specialist
M.B.Ch.B / DA / FICMS A&IC M.B.Ch.B / DA / FICMS A&IC

Member Member

IV
 Director certification

I, the chairman of the scientific council of anesthesia &

intensive care, certify that this thesis was prepared by the
candidate Dr. Ali Saadoon Hashim and submitted to our
council

Dr. Hassan Sarhan Haider

M.B.Ch.B / DA / FICMS A&IC
Chairman of the Arab board scientific council of
anesthesia and intensive care

V
 List of Contents
content Page no.
Dedication I
Acknowledgment II
List of contents VI
List of tables VII
List of Figures VIII
List of abbreviations IX
Abstract X
Introduction 1
Osteoarthritis of the Knee Joint 3
Steps for intraarticular injection technique 10
Ozone 14
Chronic Pain 18
Patients & Methods 21
Results 24
Discussion 31
Conclusion & Recommendations 34
References 36

VI
 List of Tables

Table Page Number

Table 1: comparison of the 1st visit and the

2nd visit pain score 27

Table 2: comparison of the 2nd and 3rd visit 28

Table 3: comparison of the 3rd and 4th visit 29

Table 4: comparison of the 4th and 5th visit 30

VII
 List of Figures

Figure Page Number

Figure 1: Sites for intraarticular injection. 10

Figure 2: Anatomical landmarks of the knee joint. 11

Figure 3: Aseptic technique of injection. 12

Figure 4: intraarticular injection. 12

Figure 5: Ozone Generator. 15

Figure 6: siliconized & ozone resistant syringe. 15

Figure 7: Processing of a medical ozone generator. 16

Figure 8: The Numerical Analog Pain Score System. 23

Figure 9: Mean of the Pain score and Standard deviation in the total 26
5 visits.

Figure 10: Difference in the Means & SD of pain score in the total 5 26
visits.

Figure 11: comparison between the 1st visit and the 2nd visit. 27

Figure 12: comparison of the 2nd and 3rd visit. 28

Figure 13: comparison of the 3rd and 4th visit. 29

Figure 14: comparison of the 4th and 5th visit. 30

VIII
 List of Abbreviations
OA Osteoarthritis

CDC Center of disease control & prevention

NSAIDs Non-Steroidal Anti-Inflammatory Drugs

COX Cyclooxygenase enzyme

OARSI The Osteoarthritis Research Society International

NEST Nerve electro stimulation technique

O3 Ozone

O3/O2 Ozone / Oxygen mixture

WHO World Health Organization

EEG Electroencephalogram

Ml Milliliter

μg/ml Microgram per milliliter

μg/m3 Microgram per square meter

IX
 Abstract
Background: Knee osteoarthritis is a degenerative disease of the knee joint. It is more
common in people older than 40 years. Symptoms may include joint pain, tenderness,
stiffness, locking, and sometimes an effusion. A variety of causes—hereditary,
developmental, metabolic, and mechanical—may initiate processes leading to loss of
cartilage. OA is a top cause of disability in older people. The goal of treatment in OA is to
reduce pain and improve function. There is no cure for the disease, but some treatments
attempt to slow disease progress.

Intraarticular ozone injections in knee osteoarthritis represent a complementary treatment

method which provides pain relief, decongestion, subsidence of bruises (hematomas), a
reduction in temperature and an improvement in motility. Intraarticular ozone injection is
increasingly being applied.

Aim: To evaluate the pain killing effect of 4 ozone-oxygen intra-articular injections of

knee joint osteoarthritis.

Patients & Methods It is a prospective, randomized clinical trial, done on 30 knee joints,
all patient were with history of OA of knee joint & suffering from long standing pain &
they have long history of medical therapy. After taking patient consent, 5 weekly sessions
intraarticular 5 ml (25 μg/ ml) ozone injections were done under complete aseptic
technique. Numerical Analog Pain score has been assessed and recorded before each
session.

Results: patients responded well to intraarticular ozone injection with a success rate of
86.66%. It is found that there is significant difference between different sessions and the
p-value was below 0.05 in all the time.

Conclusion: Intraarticular ozone injection has significant progressive effect in reducing

pain in knee joint osteoarthritis for 4 successive sessions.
Key words: Intraarticular ozone, Knee joint osteoarthritis, chronic pain.

X
Introduction

1
 Introduction
Osteoarthritis is a joint disease that most often affects middle-age to
elderly people. It is commonly referred to as OA or as "wear and tear" of
the joints, but we now know that OA is a disease of the entire joint,
involving the cartilage, joint lining, ligaments, and bone. Although it is
more common in older people, it is not really accurate to say that the
joints are just “wearing out.” [1] Osteoarthritis (OA) also known as
degenerative arthritis or degenerative joint disease or osteoarthrosis, is a
group of mechanical abnormalities involving degradation of joints [2],
including articular cartilage and subchondral bone.

Symptoms may include joint pain, tenderness, stiffness, locking, and

sometimes an effusion. A variety of causes—hereditary, developmental,
metabolic, and mechanical—may initiate processes leading to loss of
cartilage. When bone surfaces become less well protected by cartilage,
bone may be exposed and damaged. As a result of decreased movement
secondary to pain, regional muscles may atrophy, and ligaments may
become more lax. [3]

OA is a top cause of disability in older people. The goal of treatment in

OA is to reduce pain and improve function. There is no cure for the
disease, but some treatments attempt to slow disease progress. [1]
Treatment generally involves a combination of exercise, lifestyle
modification, and analgesics. If pain becomes debilitating, joint
replacement surgery may be used to improve the quality of life. [3]

About 27 million Americans are living with OA, the most common form
of joint disease. The lifetime risk of developing OA of the knee is about
46%, and the lifetime risk of developing OA of the hip is 25%, according
to the Johnston County Osteoarthritis Project, a long-term study from the
University of North Carolina and sponsored by the Centers for Disease
Control and Prevention (often called the CDC) and the National Institutes
of Health.[1]

The aim of this study is to find the pain killing effect of ozone-oxygen
intra-articular injection on knee joint osteoarthritis.

2
 Osteoarthritis of the Knee Joint

Knee osteoarthritis is a degenerative disease of the knee joint. It is more

common in people older than 40 years. Women are more likely to be
affected.[4]

Signs and symptoms [4]

Some of the signs and symptoms associated with knee osteoarthritis

include:

 Pain

 Stiffness

 Decreasing range of motion

 Muscle weakness and atrophy (particularly of quadriceps femoris,

muscle on front of thigh) due to inactivity or stiffness

 Crepitus

 Effusion-increase in quantity of synovial fluid leading to swelling

 Deformity[5]

 Baker's cyst (a harmless but sometimes painful collection of joint

fluid behind the knee)

Causes

Osteoarthritis of the knee is predominately considered a "wear and tear"

process, where there is gradual degradation of the hyaline cartilage that
covers the articulating surfaces of the bones in the knee joint. The medial
compartment of the knee (the half closest to the other knee) is affected
almost 5 times as frequently as the lateral compartment.[6] and it is
estimated that in a normal knee the moving load on the medial side is two
and half times greater than on the lateral side.[7]

In most people, the disease is either post-traumatic or hereditary.

3
Causes or contributing factors may include [7]:

 Trauma

 Elements injury of the knee joint

o Tear of meniscus

o Partial menisectomy via arthroscopy

 Recurrent patellar dislocation and patella fracture

 Interarticular fractures of the knee and knee dislocations

 Other forms of arthritis

 Weak front thigh muscles ("weak quads")[8] and associated gait

(quad avoidance gait combines keeping knee fully extended
throughout stance with excessive forward lean of the trunk)[9]

 Deformities of the knee joint that include:

o Genu varum ("bow-legs", for medial compartment knee OA)

o Genu recurvatum (Knee hyperextension)

o Knee flexion deformity

 Ligamentous instability

o Anterior cruciate ligament

o Posterior cruciate ligament

o Medial collateral ligament

o Lateral collateral ligament

 Obesity

 Genetics factors

 Osteochondritis dissecans disease

 Meniscal cyst

 Discoid meniscus

4
Pathophysiology

The most important characteristic of knee osteoarthritis is degeneration of

the articular cartilage in the knee joint. Osteoarthritis of the knee can
involve one, two, or all three compartments of the knee:

 Medial or lateral compartments of the tibiofemoral joint (between

the femur and the tibia)

 Patellofemoral joint (between the femur and patella)[10]

Diagnosis

 Joint space narrowing

 Osteophyte formation at the joint margins

 Subchondral Sclerosis (new subchondral bone formation in

response to stress on the bone)

 Subchondral Cyst formation (joint fluid under pressure gets into

cracks in the cartilage)[10]

Epidemiology

Globally approximately 250 million people have osteoarthritis of the knee

(3.6% of the population).[10]

Management of Osteoarthritis

Lifestyle modification (such as weight loss and exercise) and analgesics

are the mainstay of treatment. Acetaminophen / paracetamol is used first
line and NSAIDs are only recommended as add on therapy if pain relief
is not sufficient. [11] This is due to the relative greater safety of
acetaminophen. [11]

5
A. Lifestyle modification

For overweight people, weight loss may be an important factor, (the

widely cited Framingham Study found that a loss of 5 kg reduced the risk
of symptoms by more than 50% in overweight women following a
diagnosis of radiographic knee OA)[12]. Patient education has been shown
to be helpful in the self-management of arthritis. It decreases pain,
improving function, reducing stiffness and fatigue, and reducing medical
usage. [13] A meta-analysis has shown patient education can provide on
average 20% more pain relief when compared to NSAIDs alone in
patients with hip OA. [13]

Low Impact Aerobic Exercise (walking, bike or stationary bike,

swimming or water aerobics) and lifestyle changes also including: never
attempting to ski when joints are painful, walking only on level, even
terrain, cycling instead of running, avoiding stairs when possible and
using handrails when not possible, avoiding the carrying of heavy objects
or being on one's feet more than one hour at a time, stretching legs when
seated, avoiding low seats or having to kneel). [14]

B. Physical measures

For most people with OA, graded exercise should be the mainstay of their
self-management. Moderate exercise leads to improved functioning and
decreased pain in people with osteoarthritis of the knee. [13] While there
are some evidence for certain physical therapies evidence for the
combined program is limited. [15]

 Aims of physical therapy include[15]:

o Pain and spasm relief

o Reducing stiffness

o Muscles strengthening (stronger quads in particular can help

minimize the destabilization that occurs as ligaments lose
their tightness following cartilage loss)

o Increasing range of motion

6
 o Increasing flexibility

o Gait training

o Balance improvement

o Patient education

o Prescribing Orthotics to fix genu valgum or varum

o Increasing functional activities

There is sufficient evidence to indicate that physical interventions can

reduce pain and improve function. [16] There is some evidence that
manual therapy is more effective than exercise for the treatment of hip
osteoarthritis, however this evidence could be considered to be
inconclusive. [17] Functional, gait, and balance training has been
recommended to address impairments of proprioception, balance, and
strength in individuals with knee arthritis as these can contribute to higher
falls in older individuals. [18]

C. Orthotics& Assistive devices

The use of orthoses (commonly referred to as splints, braces or insoles as
applicable) can reduce the symptoms of osteoarthritis at various joints. In
the lower limb, orthoses are used for the foot and ankle [19] and knee. [20]
In the upper limb, splinting of the base of the thumb leads to
improvements after one year. Assistive devices (walker, cane in the hand
opposite the affected knee, custom fit "unloader brace" which laterally
transfers loading off of the affected knee compartment)[21]

D. Medication

1. Analgesics

Acetaminophen is the first line treatment for OA. [11][22] For mild to
moderate symptoms effectiveness is similar to non-steroidal anti-
inflammatory drugs (NSAIDs), though for more severe symptoms
NSAIDs may be more effective. [11] NSAIDs such as ibuprofen while
more effective in severe cases are associated with greater side effects
such as gastrointestinal bleeding. [11] Another class of NSAIDs, COX-2

7
selective inhibitors (such as celecoxib) are equally effective to NSAIDs
with lower rates of adverse gastrointestinal adverse effects but higher
rates of cardiovascular disease such as myocardial infarction. [23] They are
also much more expensive. There are several NSAIDs available for
topical use including diclofenac. They have fewer systemic side-effects
and at least some therapeutic effect. [24] While opioid analgesic such as
morphine and fentanyl improve pain this benefit is outweighed by
frequent adverse events and thus they should not routinely be used. [25]

2. Steroids

Oral steroids are not recommended in the treatment of OA because of

their modest benefit and high rate of adverse effects. Injection of
glucocorticoids (such as hydrocortisone) leads to short term pain relief
that may last between a few weeks and a few months. [26]

3. Hyaluronic Acid

Joint injections of hyaluronic acid have not been found to lead to

significant improvement. [24][27]Hyaluronic acid injects have been
associated with significant harm. [27]

4. Glucosamine

Controversy surrounds glucosamine. [28] A 2010 meta-analysis has found

that it is no better than placebo. [29] Some older reviews conclude that
glucosamine sulfate was an effective treatment [30][31] while some others
have found it ineffective. [32][33] A difference has been found between
trials involving glucosamine sulfate and glucosamine hydrochloride, with
glucosamine sulfate showing a benefit and glucosamine hydrochloride
not. The Osteoarthritis Research Society International (OARSI)
recommends that glucosamine be discontinued if no effect is observed
after six months. [34]

5. Intraarticular Ozone Injections

Intraarticular ozone injections in knee osteoarthritis represent a

complementary treatment method which provides rapid pain relief,
decongestion, subsidence of bruises (hematomas), a reduction in
temperature and an improvement in motility. It involves knee and
shoulder joints presenting chronic pathological symptoms. [35]

8
Intraarticular ozone injection is increasingly being applied with success,
particularly in orthopedic practices, where inflammatory and degenerative
diseases of the bones and joints as well as posttraumatic conditions (i.e.
following sport injuries) and surgery of the large joints are involved. [35]

Intraarticular injection of an ozone/oxygen gas mixture must be

considered as being minimal invasive intervention in a sterile system
(joint), to be carried out under especially strict aseptic precautionary
measures. In addition the ozone unit must be cleaned every day after use
as hygiene requires , and additionally disinfected by wet wiping with
corresponding agents (surface disinfectants) when contamination with
blood has occurred. Regular maintenance of the unit must also be counted
as hygienic safety. [35]

6. Alternative Medicines

Many alternative medicines are purporting to decrease pain associated

with arthritis. However, there is little evidence supporting benefits for
most alternative treatments including:

a. vitamin A, C, and E, ginger, turmeric, omega-3 fatty acids, &

chondroitin sulfate. These treatments are thus not recommended. [36][37] S-
Adenosyl methionine may relieve pain similar to nonsteroidal anti-
inflammatory drugs. [38][39]

b. Acupuncture A Cochrane review found that while acupuncture

leads to a statistically significant improvement in pain relief, this
improvement is small and may be of questionable clinical significance.
Waiting list-controlled trials for peripheral joint osteoarthritis do show
clinically relevant benefits, but these may be due to placebo effects. [40]
Acupuncture does not seem to produce long-term benefits. [41]

c. Electrostimulation techniques (NEST) have been used for twenty

years to treat osteoarthritis in the knee, there is no evidence to show that
it reduces pain or disability. [42]

9
 Steps for intraarticular injection technique

STEP 1: Selecting an injection approach

Common approaches for injecting the knee include the following: [43]

1. Anterolateral (flexed knee)

2. Anteromedial (flexed knee)

3. Superolateral/lateral suprapatellar (straight knee)

4. Superomedial/medial suprapatellar (straight knee)

5. Lateral mid-patellar

6. Medial mid-patellar.

One study found that the accuracy of the first attempt at needle placement
was highest for lateral mid-patellar (93%) compared with anteromedial
(75%) and anterolateral (71%) approaches (superolateral approach not
done).[43]

Figure 1: Sites for intraarticular injection.

10
STEP 2: Identify and mark the injection site [44]

Mark where lines intersect as in diagram.

If the patient cannot completely extend the knee, placement of a rolled

towel to support the knee will help provide the patient comfort and
minimize muscle spasm, improving the likelihood of a successful and
comfortable injection.

Figure 2: Anatomical landmarks of the knee joint.

STEP 3: Preparing the injection site [44]

Aseptic technique

– Swab area 3 times with a povidone iodine preparation (Beta-dine) and

let dry.

Local anesthetic options

– Lidocaine

– Vapocoolant spray

11
 Figure 3: Aseptic technique of injection

STEP 4: Injection [44]

Insert needle 20- or 22-gauge for injection.

Inject the medication.

Remove needle, wipe off povidone iodine solution, and apply bandage.

Figure 4: intraarticular injection

12
STEP 5: Post-injection care: [44]

Setting patient expectations and managing adverse effects

Patient should avoid strenuous activity for 1 to 2 days after injection and
apply ice to injection site

Mild pain or swelling at the injection site can occur, but is rare

– If mild pain or swelling occurs, recommend ice, nonsteroidal anti-

inflammatory drug (NSAID), rest, and elevation

Surgery
If disability is significant and the above management is ineffective,
Surgical operations can include the following:[11]

 Total or partial knee replacement (Arthroplasty of the knee)

 Femoral osteotomy

 Tibial osteotomy

 Arthroscopic debridement (so-called "clean out"). Debridement

may be done for these knee problems:

o Damaged cartilage

o Damaged meniscus

o The presence of loose bodies in knee joint

o Osteophytes of the joint

o Synovial hypertrophy (by synovectomy)

 Osteochondral allograft (bulk or mosaic)

 Arthrodesis (Fusion)

13
 Ozone
The natural gas ozone has been widely used in the last decades to treat
several pathologies in conjunction with oxygen. Nevertheless, any efforts
have been carried out recently to overcome the lack of randomized
clinical studies is trying to collect a wide number of direct clinical
observations with more accurate epidemiological studies [45].

Medical Ozone as a Pharmaceutical Agent

Pharmaceuticals in the gaseous state are exceptional and special forms of

application are required. In the case of medical ozone/oxygen mixtures,
oxygen is not only used as a generator gas to produce the corresponding
ozone mixture, but also, at the same time, as a solvent in the range from
0.05 to max. 5.0 vol% ozone, corresponding to the concentration range of
1.0 to 100 μg/ml ozone applied in practice[35].

Preparation and Measurement

Contrary to technical and smog ozone, the O3 used in medicine is

produced from pure medical oxygen via silent electrical discharge; it is
not possible to use oxygen concentrators or oxygen/air mixtures due to
their nitrogen component and the consequent possibility of nitrogen
oxides being formed in the discharge tube.[35].

14
 Figure 5: Ozone Generator

As with other pharmaceuticals, medical ozone is a clearly defined

molecule with a clearly defined range of action. With a half-life of 55
minutes in a 5 ml disposable injection syringe (completely siliconized and
ozone resistant), medical ozone must be prepared on site and made
especially available for the type of application required.[35].

Figure 6: siliconized & ozone resistant syringe

15
As the concentration and decomposition rate of ozone is extremely
dependent on different parameters such as temperature, pressure, volume,
flow rate etc., medical ozone generators have to be equipped with a
measurement device to ensure continuous concentration control. Ozone
produced in excess, either as part of the generator gas or after local
application, must always be completely reduced back to oxygen to avoid
odor and inconvenience to the respiratory tract; correspondingly, the
system must be equipped with high-power catalysts (due to temperature
and burning risk active carbon must not be used). The maximum work
place concentration is 200 μg/m3; the maximum emission concentration
of 120 μg ozone/m3 is cited for use within closed areas (WHO).[35].

Figure 7: Processing of a medical ozone generator

16
Examples on the Therapeutic Application of Medical Ozone[35].

1. Intraarticular Ozone Injection e.g. Knee OA

2. Intradiscal Injections e.g. disc prolapse

3. Rectal Ozone/Oxygen Insufflation e.g. irritable bowel syndrome

4. Topical Ozone Applications e.g. acne & dermatitis

a. Ozonized Water

b. Ozone cream (Ozonides and Peroxides)

5. Minor Autohaemotherapy with Ozone

6. Major Auto Haemotherapy with Ozone as a Systemic Application

7. Subcutaneous and Intracutaneous Application (O3/O2 blistering)

Mechanism of action in osteoarthritis:

Ozone (O3) is an allotrope of oxygen; it interacts with some pain

mediators. This may involve algesic mediators or receptors. The
analgesic mechanism induced by O3/O2 may involve 2 independent steps:
a short-term mechanism that may correspond with the direct oxidation on
biomolecules, and a long-term mechanism that may involve the activation
of antioxidant pathways. [46] Its strong oxidation is known to use one of
the strongest oxidants and has a strong anti-inflammatory and analgesic
effects present in the study of ozone treatment of knee the relevant
section of the mechanism of arthritis are: (1 inhibition of bradykinin
release and inhibit the synthesis of inflammatory mediators PGs reduce
pain (2 anti-inflammatory and inhibit the immune response (3 act directly
on nerve endings and stimulate the middle of the inhibitory neurons
release of cerebral knee skin and other substances, to achieve analgesic
effect (4 to change the internal environment of the joint cavity, so as to
promote repair and regeneration of articular cartilage, slow down joint
recession velocity [47].

17
 Chronic Pain

Definition pain is unpleasant sensory & emotional experience associated

with actual or potential tissue damage or described in terms of such
damage. [48]

Chronic pain is pain that has lasted for a long time. The American chronic
pain association defines it as Pain that continues a month or more beyond
the usual recovery period. Some has described chronic pain as pain
persisting more than 3 month, as by three months pain itself becomes a
disease. All pain is acute pain till it becomes chronic pain. [48]

In medicine, the distinction between acute and chronic pain has

traditionally been determined by an arbitrary interval of time since
onset;[49] the two most commonly used markers being 3 months and 6
months since onset, though some theorists and researchers have placed
the transition from acute to chronic pain at 12 months[50]. Others apply
acute to pain that lasts less than 30 days, chronic to pain of more than six
months duration, and subacute to pain that lasts from one to six
months[51]. A popular alternative definition of chronic pain, involving no
arbitrarily fixed durations is "pain that extends beyond the expected
period of healing."[49]

Classification

Chronic pain may be divided into "nociceptive" (caused by activation of

nociceptors), and "neuropathic" (caused by damage to or malfunction of
the nervous system).[52]

Nociceptive pain may be divided into "superficial" and "deep".[52]

Deep pain into "deep somatic" and "visceral" .[52]

Superficial pain is initiated by activation of nociceptors in the skin or

superficial tissues. [52]

18
Deep somatic pain is initiated by stimulation of nociceptors in ligaments,
tendons, bones, blood vessels, fasciae and muscles, and is dull, aching,
poorly-localized pain. Visceral pain originates in the viscera (organs).
Visceral pain may be well-localized, but often it is extremely difficult to
locate, and several visceral regions produce "referred" pain when
damaged or inflamed, where the sensation is located in an area distant
from the site of pathology or injury.[53]

Neuropathic pain is divided into "peripheral" (originating in the

peripheral nervous system) and "central" (originating in the brain or
spinal cord).[54] Peripheral neuropathic pain is often described as
“burning,” “tingling,” “electrical,” “stabbing,” or “pins and needles”.[55]

Pathophysiology

Under persistent activation nociceptive transmission to the dorsal horn

may induce a wind up phenomenon. This induces pathological changes
that lower the threshold for pain signals to be transmitted. In addition it
may generate nonnociceptive nerve fibers to respond to pain signals.
Nonnociceptive nerve fibers may also be able to generate and transmit
pain signals. In chronic pain this process is difficult to reverse or
eradicate once established.[56]

Chronic pain of different etiologies has been characterized as a disease

affecting brain structure and function. Magnetic resonance imaging
studies have shown abnormal anatomical[57] and functional connectivity,
even during rest[58][59] involving areas related to the processing of pain.
Also, persistent pain has been shown to cause grey matter loss, reversible
once the pain has resolved.[60][61]

These structural changes can be explained by the phenomenon known as

neuroplasticity. In the case of chronic pain, the somatototic representation
of the body is inappropriately reorganized following peripheral and
central sensitization. This maladaptative change results in the experience
of allodynia and/or hyperalgesia. Brain activity in individuals suffering
from chronic pain, measured via electroencephalogram (EEG), has been
demonstrated to be altered, suggesting pain-induced neuroplastic
changes. More specifically, the relative beta activity (compared to the rest
of the brain) is increased, the relative alpha activity is decreased, and the
theta activity both absolutely and relatively is diminished.[62]

19
Management of Chronic Pain

Complete and sustained remission of many neuropathies and most

idiopathic chronic pain (pain that extends beyond the expected period of
healing, or chronic pain that has no known underlying pathology) is
rarely achieved, but much can be done to reduce suffering and improve
quality of life. [63]

Pain management is the branch of medicine employing an

interdisciplinary approach to the relief of pain and improvement in the
quality of life of those living with pain.[64] The typical pain management
team includes medical practitioners, clinical psychologists,
physiotherapists, occupational therapists, and nurse practitioners.[65]Acute
pain usually resolves with the efforts of one practitioner; however, the
management of chronic pain frequently requires the coordinated efforts of
the treatment team.[66][67][68]

Psychological treatments including cognitive behavioral therapy[69][70] and

acceptance and commitment therapy[71] have been shown effective for
improving quality of life in those suffering from chronic pain. Clinical
hypnosis, including self-hypnosis, has been shown effective not only for
improving quality of life, but for direct improvement of chronic pain
symptoms.[71][72][73]

The emergence of studies relating chronic pain to neuroplasticity also

suggests the utilization of neurofeedback rehabilitation techniques to
resolve maladaptive cortical changes and patterns. The proposed goal of
neurofeedback intervention is to abolish maladaptive neuroplastic
changes made as a result of chronic nociception, as measured by
abnormal EEG, and thereby relieve the individual's pain. However, this
field of research lacks randomized control trials, and therefore requires
further investigation.[62]

20
Patients & Methods

21
 Patients & Methods
It is a prospective, randomized clinical trial, done on 30 knee joints, all
patient were with history of OA of knee joint & suffering from long
standing pain & they have long history of medical therapy.

This study has been carried out in the pain clinic of the Nursing Home
Hospital/ Medical City Complex/ Baghdad-Iraq, from October 2012 to
February 2013.

Carful & detailed history has been taken, regarding the pain (site, type,
time, radiation, frequency, duration, severity) and also clinical
examination was performed with radiological imaging to confirm the
diagnosis of knee OA.

Exclusion criteria:

1. Patient refusal.

2. Any coexisting intraarticular injection of another medication in the last

six months.

3. Uncontrolled Diabetes Mellitus.

4. Patients that can be treated by analgesic medications.

Performance

After taking patient consent, prior to ozone application, the standard

injection points; (either anterolateral or anteromedial), should be prepared
for injection under complete aseptic technique.

All the injection was performed by the same person.

Then intraarticular local anesthetic (2 ml of 2% lidocaine) is given to

minimize the burning sensation that may be caused by the ozone.

22
For intraarticular ozone injections, the same needle is kept in place to
reduce the number of skin bricking, a volume of approximately 5 ml of
medical ozone as a gas is given, this injection repeated for 5 sessions, 1
week apart. In each case, the ozone concentration is 25 μg/ml.

Numerical Analog Pain score on exercise has been assessed and recorded
before each session by instructing the patient to choose a number from 0
to 10 that best describes their current pain. 0 would mean ‘No pain’ and
10 would mean ‘Worst possible pain’. (Figure no. 8)

Figure 8 - The Numerical Analog Pain Score System.

The 1st visit pain score record reveals the pain before ozone injection.

In the subsequent visits, (2nd, 3rd, 4th& 5th), each record reveals the effect
of the previous injection.

After completing all the 5 visits for all patients, the data statically
analyzed & regarded as significant when the P value is less than (0.05).

23
Results

24
 Results

In this prospective study total number of knee joints were 34, 4 cases
were unable to complete the whole procedure due to their personal
noncompliance to injection cessions. So, only 30 cases were included in
the study. It is interesting to note that patients responded well to
intraarticular ozone injection with a success rate of 86.66%.Using the
IBM SPSS Statistics 20 by the paired group t-student T-test we found that
there is significant difference between visit and another for the patients
where the p-value was below 0.05 in all the time as shown by the
following tables and graphs:

25
9

5
mean
4 S.D
3

0
1st visit 2nd visit 3rd visit 4th visit 5th visit

Figure 9: Mean of the Pain score and Standard deviation in the total 5 visits.

9
8
7
6
5
4 mean
3 S.D
2
1
0
1st visit
2nd visit
3rd visit
4th visit
5th visit

Figure 10: Difference in the Means & SD of pain score in the total 5 visits.

26
Table 1: comparison of the 1st visit and the 2nd visit pain score

Standard
No. of cases Mean P-Value
deviation

1st visit 30 8.2188 1.43087

0.0002

2nd visit 30 6.6250 2.07520

9
8
7
6
Mean
5
S.D
4
3
2
1
0
1st visit 2nd visit

Figure 11: comparison between the 1st visit and the 2nd visit

27
Table 2: comparison of the 2nd and 3rd visit

Standard
No. of cases Mean P-Value
deviation

2nd visit 30 6.6250 2.07520

0.0001

3rd visit 30 5.8125 2.33401

4 Mean
S.D
3

0
2nd visit 3rd visit

Figure 12: comparison of the 2nd and 3rd visit

28
Table 3: comparison of the 3rd and 4th visit

Standard
No. of cases Mean P-Value
deviation

3nd visit 30 5.8125 2.33401

0.0004

4th visit 30 4.7188 2.18845

4
Mean
3 S.D

0
3rd visit 4th visit

Figure 13: comparison of the 3rd and 4th visit

29
Table 4: comparison of the 4th and 5th visit

Standard
No. of cases Mean P-Value
deviation

4th visit 30 4.7188 2.18845

0.0002

5th visit 30 3.7188 2.61798

5
4.5
4
3.5
3 Mean
2.5 S.D
2
1.5
1
0.5
0
4th visit 5th visit

Figure 14: comparison of the 4th and 5th visit

30
Discussion

31
 Discussion

Analysis of the result findings in our study on overall patient response to

intraarticular injection of medical ozone there is progressive reduction in
pain intensity which was assessed by the numerical analog pain score
from the 1st visit till completing the whole procedure (figure 1 and figure
2). The overall patient response success rate was 86.66%.

By using the paired group t-student T-test we found that there is

significant difference between visit and another for the patients where the
p-value was below 0.05 in all the time as mentioned in table 1 which
compare between the 1st visit and the 2nd visit pain score (figure 3), table
2 which compare between the 2nd visit and the 3rd visit pain score (figure
4), table 3 which compare between the 3rd visit and the 4th visit pain
score (figure 5), and in table 4 which compare between the 4th visit and
the 5th visit pain score (figure 6).

Ahmed Al-Jaziri etal, studied the painkilling effect of intra-

articular ozone-oxygen injection on 114 knee joint osteoarthritis of 72
patients. Using the six faces pain scale; the patients’ pains were recorded
before intervention and at 4th, 8th and 12th sessions of treatment. The
involved knee joints were injected by intra-articular ozone-oxygen
mixture, 20 mcg/ml, twice a week for 12 sessions. The authors did all the
injections and a nurse recorded the pain scales. Seventy two patients
having a radiologically documented mild to moderate knee joint
osteoarthritis were treated during 19 months (September 2002 – March
2004). They were followed for a mean of 8.48 months and their pain
scales were recorded at the follow-up time too. Comparison of the
patients’ 1st day pains with their pains at 4th, 8th and 12th sessions
showed a significant decrease (1st day to 4th session p=0.005, 1st day to
8th week p=0.005, 1st day to 12th session P<0.005). This study validates
the painkilling effect of ozone-oxygen intra-articular injection on knee
joint osteoarthritis. [74]

32
 Carlos Huanqui etal, also studied the intraarticular ozone therapy in
patient with knee osteoarthritis resistant to anti-inflammatory treatment
on one hundred and eighty patients with diagnosis of primary knee
osteoarthritis grade III were evaluated, all of them with poor clinical
answer to non-steroidal anti-inflammatory drugs. They received intra-
articular ozone in knees, in 5 first applications of 5 cc at doses of 15
µg/ml and 20 µg/ml the 3 remaining sessions of 2 weekly applications in
one or both involved joints. In order to evaluate the clinical effects on
pain, joint rigidity and functional difficulty, the authors use the WOMAC
instrument in its version of Likert score. Data were analyzed with
descriptive statistics with frequency, central tendency and dispersion
measures. The authors employed Student’s paired t test and analysis of
variance (ANOVA). There was a progressive and significant lowering of
global scores at 7, 14 and 28 days of evaluation with the ozone intra-
articular application. At the end of treatment, the proportional
improvement in the three clinical parameters evaluated was 52 %.
Adverse effects were minimal, concomitant administration of NSAIDs
was importantly reduced. They conclude that intra-articular ozone is an
effective therapy in the treatment of grade III knee osteoarthritis resistant
to treatment with NSAIDs. [75]

Both studies that previously mentioned above, were agreed with our
result in that ozone has a significant progressive pain killing effect when
given as successive intraarticular injections in patients known to have
knee joint osteoarthritis.

33
 Conclusion
&
Recommendations

34
 Conclusion
Intraarticular ozone injection has significant effect in reducing pain in
knee joint osteoarthritis after repeating the injection for five successive
sessions.

Recommendations
Intraarticular injection of 5 ml of medical ozone in the treatment of pain
in knee joint osteoarthritis in a dose of 25 μg /ml, for five successive
sessions, one week apart is a recommended course of treatment.

Further studies for intraarticular ozone injection for more number of

cases, longer duration of follow up, the use of different concentrations, &
comparing the effect with other types of treatment also recommended.

35
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36
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40
 ‫اﻟﺨﻼﺻﺔ‬
‫اﻟﺨﻠﻔﯿﺔ‪ :‬ان اﻟﺘﮭﺎب ﻣﻔﺎﺻﻞ اﻟﺮﻛﺒﺔ ھﻮ ﻣﺮض اﻧﺤﻼﻟﻲ ﯾﺼﯿﺐ ﻣﻔﺼﻞ اﻟﺮﻛﺒﺔ‪ .‬وھﻮ أﻛﺜﺮ ﺷﯿﻮﻋﺎ‬
‫ﻋﻨﺪ ﻛﺒﺎر اﻟﺴﻦ ﻣﻦ ‪ 40‬ﻋﺎﻣﺎ‪ .‬ﻗﺪ ﺗﺘﻀﻤﻦ اﻷﻋﺮاض آﻻم اﻟﻤﻔﺎﺻﻞ‪ ،‬واﻟﺘﺄﻟﻢ ﻋﻨﺪ اﻟﻠﻤﺲ‪ ،‬واﻟﺘﺼﻠﺐ‪،‬‬
‫واﻹﻗﻔﺎل‪ ،‬وأﺣﯿﺎﻧﺎ اﻻﺳﺘﺴﻘﺎء‪ .‬ھﻨﺎك ﻣﺠﻤﻮﻋﺔ ﻣﺘﻨﻮﻋﺔ ﻣﻦ اﻷﺳﺒﺎب ﻣﻨﮭﺎ اﻟﻮراﺛﯿﺔ واﻟﺘﻨﻤﻮﯾﺔ‬
‫واﻻﯾﻀﯿﺔ واﻟﻤﯿﻜﺎﻧﯿﻜﯿﺔ‪ ،‬ﺗﺴﺒﺐ اﻟﺸﺮوع ﻓﻲ اﻟﻌﻤﻠﯿﺎت اﻟﻤﺆدﯾﺔ إﻟﻰ ﻓﻘﺪان اﻟﻐﻀﺮوف ‪ .‬ان ﻣﺮض‬
‫ﺳﻮﻓﺎن اﻟﻤﻔﺎﺻﻞ ھﻮ اﻟﺴﺒﺐ اﻟﺮﺋﯿﺲ ﻟﻠﻌﺠﺰ ﻋﻨﺪ ﻛﺒﺎر اﻟﺴﻦ‪ .‬وان اﻟﮭﺪف ﻣﻦ اﻟﻌﻼج ھﻮ ﻟﻠﺤﺪ ﻣﻦ‬
‫اﻷﻟﻢ و ﺗﺤﺴﯿﻦ اﻟﻮظﯿﻔﺔ‪ .‬ﻻ ﯾﻮﺟﺪ ﻋﻼج ﻟﮭﺬا اﻟﻤﺮض‪ ،‬وﻟﻜﻦ ﺑﻌﺾ اﻟﻌﻼﺟﺎت ﻣﺤﺎوﻟﺔ ﻹﺑﻄﺎء ﺗﻘﺪم‬
‫اﻟﻤﺮض‪.‬‬

‫ﺣﻘﻦ اﻷوزون داﺧﻞ اﻟﻤﻔﺼﻞ ﻓﻲ اﻟﺘﮭﺎب ﻣﻔﺎﺻﻞ اﻟﺮﻛﺒﺔ ﺗﻤﺜﻞ أﺳﻠﻮب اﻟﻌﻼج اﻟﺘﻜﻤﯿﻠﻲ اﻟﺬي ﯾﻮﻓﺮ‬
‫اﻟﺘﺨﻔﯿﻒ اﻟﺴﺮﯾﻊ ﻟﻶﻻم‪ ،‬ﺗﺨﻔﯿﻒ اﻻﺣﺘﻘﺎن‪ ،‬ھﺒﻮط اﻟﻜﺪﻣﺎت )اﻟﻘﯿﻠﺔ اﻟﺪﻣﻮﯾﺔ(‪ ،‬اﻧﺨﻔﺎض ﻓﻲ درﺟﺎت‬
‫اﻟﺤﺮارة وﺗﺤﺴﻦ ﻓﻲ اﻟﺤﺮﻛﺔ‪ .‬ان اﻟﻌﻼج ﺑﺤﻘﻦ اﻷوزون داﺧﻞ اﻟﻤﻔﺼﻞ ﯾﺠﺮي ﺗﻄﺒﯿﻘﮭﺎ ﺑﻨﺠﺎح و‬
‫ﺑﺸﻜﻞ ﻣﺘﺰاﯾﺪ ‪ ،‬وﻻ ﺳﯿﻤﺎ ﻓﻲ ﻣﻤﺎرﺳﺎت طﺐ اﻟﻌﻈﺎم ‪ ،‬ﺣﯿﺚ ﺗﺸﺎرك اﻷﻣﺮاض اﻻﻟﺘﮭﺎﺑﯿﺔ واﻟﺘﻨﻜﺴﯿﺔ‬
‫ﻓﻲ اﻟﻤﻔﺎﺻﻞ واﻟﻌﻈﺎم وﻛﺬﻟﻚ ظﺮوف ﻣﺎ ﺑﻌﺪ اﻟﺼﺪﻣﺔ )أي إﺻﺎﺑﺎت اﻟﺮﯾﺎﺿﺔ( وﺟﺮاﺣﺔ اﻟﻤﻔﺎﺻﻞ‬
‫اﻟﻜﺒﯿﺮة‪.‬‬

‫اﻟﮭﺪف ‪ :‬اﻟﮭﺪف ﻣﻦ ھﺬه اﻟﺪراﺳﺔ ھﻮ إﯾﺠﺎد اﻟﺘﺄﺛﯿﺮ اﻟﻤﺜﺒﻂ ﻟﻶﻻم ﻟﺤﻘﻦ اﻻوزون داﺧﻞ اﻟﻤﻔﺼﻞ‬
‫ﻋﻠﻰ ﺳﻮﻓﺎن ﻣﻔﺼﻞ اﻟﺮﻛﺒﺔ‪.‬‬

‫اﻟﻤﺮﺿﻰ وطﺮﯾﻘﺔ اﻟﻌﻤﻞ‪ :‬اﻟﺪراﺳﺔ اﺣﺘﻤﺎﻟﯿﺔ‪ ,‬ﻋﺸﻮاﺋﯿﺔ‪ ,‬ﺷﻤﻠﺖ ‪ 30‬ﻣﻔﺼﻞ رﻛﺒﺔ‪ ,‬ﺟﻤﯿﻊ اﻟﻤﺮﺿﻰ‬
‫ﻟﺪﯾﮭﻢ ﺳﻮﻓﺎن ﻣﻔﺼﻞ اﻟﺮﻛﺒﺔ وﯾﻌﺎﻧﻮن ﻣﻦ اﻻﻻم اﻟﻤﺰﻣﻨﺔ وﻟﺪﯾﮭﻢ ﺗﺎرﯾﺦ طﻮﯾﻞ اﻻﻣﺪ ﻣﻦ اﻟﻌﻼج‬
‫اﻟﻄﺒﻲ‪ .‬ﺑﻌﺪ اﻟﺤﺼﻮل ﻋﻠﻰ ﻣﻮاﻓﻘﺔ اﻟﻤﺮﯾﺾ‪ ,‬ﯾﺘﻢ اﻟﺘﺤﻈﯿﺮ ﻟﺤﻘﻦ اﻻوزون‪ ,‬ﯾﺘﻢ ﺗﺤﺪﯾﺪ ﻧﻘﺎط اﻟﺤﻘﻦ‬
‫اﻟﻘﯿﺎﺳﯿﺔ )اﻣﺎ اﻣﺎﻣﻲ ﺟﺎﻧﺒﻲ او اﻣﺎﻣﻲ اﻧﺴﻲ( ﯾﺠﺐ أن ﺗﻜﻮن ﻣﻌﺪة ﻟﺘﻘﻨﯿﺔ اﻟﺤﻘﻦ ﺗﺤﺖ اﻟﺘﻌﻘﯿﻢ اﻟﻜﺎﻣﻞ‪.‬‬
‫ﺛﻢ ﯾﺘﻢ إﻋﻄﺎء ﻣﺨﺪر ﻣﻮﺿﻌﻲ داﺧﻞ اﻟﻤﻔﺼﻞ )‪ 2‬ﻣﻞ ﻣﻦ اﻟﻠﯿﺪوﻛﺎﯾﻦ ‪ (%2‬ﻟﻠﺤﺪ ﻣﻦ اﻟﺤﺮﻗﺎن اﻟﺬي‬
‫ﻗﺪ ﯾﻜﻮن ﻧﺎﺟﻤﺎ ﻋﻦ اﻷوزون‪ .‬ﻟﺤﻘﻦ اﻷوزون داﺧﻞ اﻟﻤﻔﺼﻞ‪ ،‬ﯾﺘﻢ ﺗﺮك اﻹﺑﺮة ﻓﻲ ﻧﻔﺲ اﻟﻤﻜﺎن ﻟﻠﺤﺪ‬
‫ﻣﻦ ﻋﺪد ﻣﺮات ﺣﻘﻦ اﻟﺠﻠﺪ‪ ،‬ﯾﺘﻢ إﻋﻄﺎء ﺣﺠﻢ ﻣﺎ ﯾﻘﺮب ﻣﻦ ‪ 5‬ﻣﻞ ﻣﻦ اﻷوزون اﻟﻄﺒﻲ ﻛﻐﺎز ‪,‬ﺗﺘﻜﺮر‬
‫ھﺬه اﻟﺤﻘﻦ ﻟﺨﻤﺲ ﺟﻠﺴﺎت‪ ،‬ﯾﻔﺼﻞ ﺑﯿﻦ ﺟﻠﺴﺔ واﺧﺮى أﺳﺒﻮع واﺣﺪ‪ .‬ﯾﻜﻮن ﺗﺮﻛﯿﺰ اﻷوزون ھﻮ ‪25‬‬
‫ﻣﯿﻜﺮوﻏﺮام ‪/‬ﻣﻞ‪ .‬ﻧﺴﺒﺔ اﻻﻟﻢ ﺗﺴﺠﻞ ﻗﺒﻞ ﻛﻞ ﺟﻠﺴﺔ اﻋﺘﻤﺎدا ﻋﻠﻰ ﻣﯿﺰان اﻻﻟﻢ اﻟﻌﺪدي‪.‬‬

‫اﻟﻨﺘﺎﺋﺞ‪ :‬ﻣﻦ اﻟﻤﺜﯿﺮ ﻟﻼھﺘﻤﺎم أن ﻧﻼﺣﻆ أن اﻟﻤﺮﺿﻰ اﻟﺬﯾﻦ اﺳﺘﺠﺎﺑﻮا ﺟﯿﺪا ﻟﺤﻘﻦ اﻷوزون داﺧﻞ‬
‫اﻟﻤﻔﺼﻞ ﻣﻊ ﻧﺴﺒﺔ ﻧﺠﺎح ﺗﺼﻞ اﻟﻰ ‪ . %86.66‬ﺑﺎﺳﺘﺨﺪام ﺑﺮﻧﺎﻣﺞ ‪IBM SPSS Statistics 20‬‬
‫وطﺮﯾﻘﺔ ‪ paired group t-student T-test‬وﺟﺪ أن ھﻨﺎك ﻓﺮق ﻛﺒﯿﺮ ﺑﯿﻦ زﯾﺎرة وأﺧﺮى‬
‫ﻟﻠﻤﺮﺿﻰ ﺣﯿﺚ ﻗﯿﻤﺔ ف ﻛﺎن أﻗﻞ ‪ 0.05‬ﻓﻲ ﻛﻞ وﻗﺖ‪.‬‬

‫اﻻﺳﺘﻨﺘﺎج ‪ :‬ان ﺣﻘﻦ اﻷوزون داﺧﻞ ﻣﻔﺼﻞ اﻟﺮﻛﺒﺔ ﻟﮫ ﺗﺄﺛﯿﺮ ﺗﺪرﯾﺠﻲ و ذو دﻻﻟﺔ ﻓﻲ اﻟﺤﺪ ﻣﻦ اﻷﻟﻢ‬
‫ﻓﻲ ﺣﺎﻻت ﺳﻮﻓﺎن اﻟﺮﻛﺒﺔ ﺑﻌﺪ ﺗﻜﺮار اﻟﺤﻘﻦ ﻟﻤﺪة ﺧﻤﺲ دورات ﻣﺘﺘﺎﻟﯿﺔ‪.‬‬
‫اﻟﻜﻠﻤﺎت اﻟﺪاﻟﺔ‪ :‬اﻷوزون داﺧﻞ اﻟﻤﻔﺼﻞ‪ ،‬اﻟﺘﮭﺎب اﻟﻤﻔﺎﺻﻞ ﻣﻔﺼﻞ اﻟﺮﻛﺒﺔ‪ ،‬واﻷﻟﻢ اﻟﻤﺰﻣﻦ‪.‬‬
 ‫اﻟﻤﺠﻠﺲ اﻟﻌﺮﺑﻲ ﻟﻼﺧﺘﺼﺎﺻﺎت اﻟﺼﺤﯿﺔ‬
‫اﻟﺘﺨﺪﯾﺮ واﻟﻌﻨﺎﯾﺔ اﻟﻤﺮﻛﺰة‬

‫ﺗﻘﯿﯿﻢ ﺗﺄﺛﯿﺮ ﺣﻘﻦ اﻻوزون ﻟﺨﻤﺴﺔ ﻣﺮات ﻣﺘﺘﺎﻟﯿﺔ‬

‫داﺧﻞ اﻟﻤﻔﺼﻞ ﻛﻤﺴﻜﻦ ﻟﻸﻟﻢ اﻟﻨﺎﺗﺞ ﻋﻦ اﻟﺘﮭﺎب‬
‫)ﺳﻮﻓﺎن( اﻟﺮﻛﺒﺔ‬

‫رﺳﺎﻟﺔ ﻣﻘدﻣﺔ إﻟﻰ اﻟﻣﺟﻠس اﻟﻌﻠﻣﻲ ﻻﺧﺗﺻﺎص اﻟﺗﺧدﯾر و‬

‫اﻟﻌﻧﺎﯾﺔ اﻟﻣرﻛزة ﻛﺟزء ﻣن ﻣﺗطﻠﺑﺎت اﻟﺣﺻول ﻋﻠﻰ ﺷﮭﺎدة‬
‫زﻣﯾل اﻟﻣﺟﻠس اﻟﻌرﺑﻲ ﻟﻼﺧﺗﺻﺎﺻﺎت اﻟطﺑﯾﺔ ﻓﻲ اﻟﺗﺧدﯾر و‬
‫اﻟﻌﻧﺎﯾﺔ اﻟﻣرﻛزة‬

‫اﻋﺪاد اﻟﺪﻛﺘﻮر‬

‫ﻋﻠﻲ ﺳﻌﺪون ھﺎﺷﻢ‬

‫طﺒﯿﺐ ﻣﺘﺪرب ﻓﻲ ﺑﺮﻧﺎﻣﺞ اﻟﻤﺠﻠﺲ اﻟﻌﺮﺑﻲ ﻟﻠﺘﺨﺪﯾﺮ و اﻟﻌﻨﺎﯾﺔ اﻟﻤﺮﻛﺰة‬

‫اﺷﺮاف اﻟﺪﻛﺘﻮر‬

‫اﯾﺎد ﻋﺒﺎس ﺳﻠﻤﺎن‬

‫اﺧﺘﺼﺎص اﻟﺘﺨﺪﯾﺮ واﻟﻌﻨﺎﯾﺔ اﻟﻤﺮﻛﺰة‬
‫ﻛﻠﯿﺔ اﻟﻄﺐ‪ /‬ﺟﺎﻣﻌﺔ ﺑﻐﺪاد‬
‫‪2013‬‬