Degenerative Changes in Lumbar Region Always Lead to Bilateral Degenerative Changes in Knee-Joints and Vice-Versa: Sensation Of

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h DOI: 10.4172/2161-0940.S4-005 A Research ISSN: 2161-0940

Special Issue Open Access Degenerative Changes in Lumbar Region Always Lead to Bilateral Degenerative Changes in Knee-Joints and Vice-Versa: Sensation of Pain Cannot Only be The Parameter of Degeneration Apurba Ganguly* Founder and Head Researcher, OPTM Research Institute, Rashbehari Avenue, Kolkata, India

Abstract The perception of pain through gait control theory was promulgated five decade ago. It involves a process of inhibitory pain modulator at the spinal cord level. The present paper aims with detailed observations, involving a large number of patients, that knee joint pain may not be felt when there are degenerative changes in the lumbar region due to disc compression. But disc compression at lumbar region always leads to degenerative changes in the knees, whether pain is felt or not. Similarly knee joint pain with degenerative tissue damage is always associated with disc compression at lumbar region, whether pain is felt or not. This phenomenon is obvious in large number of patients irrespective of sex, age, bodyweight, lifestyle and ethnic barriers, examined with either pain in knee joints or in lumbar region. This research is supported by anatomical measurements, radiological and biochemical reports. This present study revels for the first time a new method of anatomical measurements with supportive clinical observations.

joints may not always be a parameter to indicate degenerative changes Keywords: Knee joint pain; Disc compression; Back pain of these areas. The present aim of the study is proved with anatomical Introduction measurements, radiological and biochemical reports. The anatomical measurements as have been presented here are author’s own method Knee joint pain may arise from a disc protrusion in the back. The of measurements with supportive evidences of radiological parameters nerves that transmit the sensation of pain to the legs and feet are located and biochemical analysis reports. in lower back region. With ageing, discs between the vertebrae bulge out and compressed the nerves, sending pain signals. The locator of pain Materials and Methods depends on which disc is protruded. The nerves that send fibres to both the knees are located at the second, third and fourth lumbar vertebral Five hundred forty eight patients from OPTM Health care were enrolled into this study. This study was approved by the Institutional levels in the lower back area. During investigation of patients, we found Ethics Committee and all participants signed an informed consent form that if a disc is compressing the nerves on the above locators, the pain for physical examinations, blood samples collection and X-ray reports. is always felt in the knee region. Similarly, we observed in patients that if the pain is in the knee region then there is always degenerative tissue Exclusion criteria damage in the knee region. In almost all cases compression in the above Out of 548 patients, 63 patients (37 males and 26 females) were lumbar vertebral levels take place, even though patients may not feel excluded for the following reasons: any pain in the affected regions. 1) Patients with cuts, wounds, or any type of chronic skin disease Nociceptors are specialised secondary receptors responsible for (eczema, psoriasis etc.) on the back, in legs, pelvic area, inguinal (groin detection of noxious stimuli, transforming the stimuli into electrical area) and other regions (10 males and 7 females), 2) with parallel signals which are conducted to the central nervous system. They are the multiple drug dependence (4 males and 5 females), 3) with surgical free nerve endings of primary afferent A δ and C fibres inflammatory implants (8 males and 5 females), 4) with pacemaker (7 males and 2 mediators (prostaglandin, cytokines etc.) are released from damaged females), 5) with history of cancer (3 males and 4 females) and 6) with tissues and can stimulate nociceptors directly. The experience of pain history of severe neurological diseases (5 males and 3 females). is complex and subjective. The somato sensory cortex is important for localisation of pain. Functional magnetic resonance imaging Patients selection demonstrated that a posterior segment of the hypothalamus is activated The balance of patients (485) after exclusion were physically during acute pain experience. The commonest areas, which are activated include the primary and secondary somato sensory (S1 and S2), insular anterior cingulate cortex and prefrontal cortex and thalamus. These *Corresponding author: Apurba Ganguly, Founder and Head Researcher, areas are all important for pain perception [1-7]. OPTM Research Institute, 145, Rashbehari Avenue, Kolkata – 700029, India, Tel: +919830389616; E-mail: [email protected] In this presentation, we are reporting the fact that if there are degenerative changes (compression) in the lumbar vertebrae levels, in Received June 10, 2015; Accepted July 27, 2015; Published July 29, 2015 most cases, in patients we examined, it leads to degenerative changes Citation: Ganguly A (2015) The Degenerative Changes in Lumbar Region Always in the knee joints though pain may not be felt at the knee joint Lead to Bilateral Degenerative Changes in Knee-Joints and Vice-Versa: Sensation of Pain Cannot Only be The Parameter of Degeneration. Anat Physiol S4:005. immediately. Similarly in patients examined with knee joint problems doi:10.4172/2161-0940.S4-005 and pain may not be felt immediately in the back region, though in most cases, the patients have disc compression in the lumbar vertebrae Copyright: © 2015 Parsons XH. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted level. This is true irrespective of their sex, age, body weight, lifestyle and use, distribution, and reproduction in any medium, provided the original author and ethnic criteria. Pain only in any particular region in lumbar or knee source are credited.

Anat Physiol Physiology ISSN:2161-0940 Physiol, an open access journal Citation: Ganguly A (2015) The Degenerative Changes in Lumbar Region Always Lead to Bilateral Degenerative Changes in Knee-Joints and Vice- Versa: Sensation of Pain Cannot Only be The Parameter of Degeneration. Anat Physiol S3:002. doi:10.4172/2161-0940.S4-005

Page 2 of 11 examined and observations were noted in order to analyze and justify the condition of knee and ankle joints, thighs, back and calf muscles structure. For the purpose of this study, all patients were examined and analyzed for the following: • Measurements of knee gaps between the short head of biceps femoris and the surface of the bed (Figure 1) • Diameter of group of calf muscles (Figure 2) Figure 3: Showing the method of measuring the group of calf muscles of • Diameter of group of thigh muscles (Figure 3) right and left legs with the help of measuring tape. • Diameter of group of muscles connected with knee joints, 4cm above the patella (Figure 4) • Diameter of group of muscles connected with knee joints, 4cm below the patella (Figure 5) • The bilateral angles of flexion in supine, prone and standing positions (Figures 6-8) • Bilateral angles of extension in supine, prone and standing positions (Figures 9-11). These data were analyzed to examine the current quantum of damage in the muscles of both the legs and back region. Radiological Figure 4: Showing the method of measuring the group of muscles connected to right and left knee joints, 4 cm above the patella with the help of measuring pictures of both the knee joints and lumbo sacral spine were also noted tape. at that time (Figures 12-23). Biochemical parameters such as C-reactive protein (CRP), muscle creatine phosphokinase (CPK) and aldolase were measured in order to justify the degenerative changes in the muscle structure [12-14]. Control group Ninety patients including 36 males and 54 females in the age group (40->80) years were treated in our clinic 6-12 months back, were taken as control group.

Figure 5: Showing the method of measuring the group of muscles connected to right and left knee joints, 4 cm below the patella with the help of measuring tape.

Figure 1: Showing the method of measuring the knee gap between the short head biceps femoris and surface of the bed of right and left legs with the help of measuring scale. Figure 6: Showing the method of measuring the knee flexion of right and left knee joints lying in supine position with the help of Goniometer.

Final selection Out of 548 patients, after exclusion of 63 patients and control group of 90 patients, the balance 395 patients (145 males and 250 females) were subdivided into different age groups between 40 and 50, 51 and 60, 61 and 70 and 71 and above 80 years as follows: • Age group of (40-50) years: Figure 2: Showing the method of measuring the group of thigh muscles of right and left legs with the help of measuring tape. total patients 51 (13%) – male: 20 (39%) and female: 31 (61%)

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Patient No: 1, Age: 45 yrs, Sex: F

Figure 7: Showing the method of measuring the knee flexion of right and left knee joints lying in prone position with the help of Goniometer.

Show advanced bilateral degenerative osteo- Show fairly advanced degenerative lumbar

arthroses -- relatively more markedly in the spondylosis -- particularly at L3-L4, L4-L5 & lateral tibio-femoral compartments. L5-S1 levels -- along with relatively exaggerated normal lordosis of lumbar spines, as well as scoliosis -- having its convexity towards right side. No bony pathology is shown in the sacro-iliac articulation on either side.

Figure 12: Represents there is a degenerative changes in knee joints as well as lumbar region but the patient complains massive pain in the left knee joint and slight pain in lumbar region and there is no sensation of pain in the right knee as reported.

Figure 8: Showing the method of measuring the knee flexion of right and left knee joints in standing position with the help of Goniometer.

Patient No: 2, Age: 50 yrs, Sex: M

Show demineralisation of the bones around Show narrowing of the inter -- vertebral

both knee joints,with advanced back-ground space between L2-L3, along with linear Figure 9: Showing the method of measuring the knee extension of right and degenerative osteo-arthroses on both sides-- sclerosis of the opposing end-plates of their left knee joints lying in supine position with the help of Goniometer. particularly in the medial compartments-- bodies, and osteophytic lipping -- along with genu varum on the right side as suggestive of disc lesion. well.

Figure 13: Represents there is a degenerative changes in the knee joints as well as lumbar region but the patient complains massive pain in the left knee joint and moderate pain in the right knee joint but there is slight sensation of pain in the limber region as reported.

Figure 10: Showing the method of measuring the knee extension of right and left knee joints lying in prone position with the help of Goniometer.

A.P. views show early osteo-arthroses in both Show grade II spondylolisthesis of L4 vertebra on knee joints – relatively more markedly on the L5, with advanced secondary degenerative disc right side & particularly in the lateral tibio- changes between them. Break, with a gap in the femoral compartments. pars inter-articulares of L4 vertebra is also evident. Early back-ground degenerative

spondylosis -- particularly at D12-L1 & L1 -- L2 levels -- also is shown. Mild scoliosis of lumbar spines, with convexity towards left side, is evident. No bony pathology is shown in the sacro-iliac articulation on either side.

Figure 14: Represents there is a degenerative changes in both the knee joints as well as lumbar region but the patient complains massive pain in the right Figure 11: Showing the method of measuring the knee extension of right and knee joint only and there is no sensation of pain neither in left knee joint nor in left knee joints in standing position with the help of Goniometer. the lumbar region as reported.

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Patient No: 7, Age: 63 yrs, Sex: M

Show mild degree of demineralisation of the Show significant demineralisation of the A.P. views show senile demineralisation of Show lumbarisation of S1 vertebra. Advanced bones around both knee joints, with back- lumbar vertebrae, as well as the bones the bones around both knee joints, with degenerative lumbar spondylosis -- most ground osteo-arthroses on both sides-- forming pelvis, with back-ground advanced back-ground degenerative osteo- markedly at L5 - S1 level -- along with particularly in the medial compartments – degenerative lumbar spondylosis – more arthroses on both sides -- particularly in the diminution of normal lordosis of lumbar along with genu varum on the right side as markedly at L2- L3 & L5-S1 levels. No bony medial compartments – along with bilateral spines, as well as mild scoliosis -- having its well. pathology is shown in the sacro-iliac genu varum -- more on the right side. convexity towards right side -- are evident.No articulation on either side. bony pathology is shown in the sacro-iliac articulation on either side. Figure 15: Represents there is a degenerative changes on both the knee joints as well as lumbar region but the patient complains massive pain in Figure 18: Represents there is a degenerative changes in both the knee the lumbar region and moderate pain in the right knee joint but there is no joints as well as lumbar region but the patient complains massive pain in sensation of pain in the left knee joint as reported. the lumbar region and moderate pain in the left knee joint but there is no sensation of pain in the right knee joint as reported.

Patient No: 5, Age: 60 yrs, Sex: F Patient No: 8, Age: 64 yrs, Sex: M

A.P. views show senile demineralisation of A.P. & Lateral views show senile the bones around both knee joints, with demineralisation of the lumbo -sacral vertebrae, Show mild bilateral genu varum,with relative Show -- Grade I spondylolisthesis of L4 vertebra advance back -- ground degenerative osteo- with back-ground degenerative lumbar lateral instabilities of the knee joints.No other on L5. Advanced degenerative lumbar spondylosis arthroses on both sides --particularly in the associated bony change is shown on either -- particularly at L2-L3, L3-L4 & L4-L5 levels. spondylosis -- particularly at L3 - L4 & L5 - S1 side. Scoliosis of lower dorsal & upper lumbar medial compartments – along with genu levels -- along with relatively exaggerated spines,with convexity towards right side. Bilateral varum on the left side as well. normal lordosis of lumbar spines. No bony sacro-iliitis -- more markedly on the left side. pathology is shown in the sacro-iliac

articulation on either side. Figure 19: Represents there is a degenerative changes in both knee joints as Figure 16: Represents there is a degenerative changes in both the knee joints well as lumbar region but the patient complains massive pain in the left knee as well as lumbar region but the patient complains massive pain in the lumbar joint and there is no sensation of pain in the right knee joint and in the lumbar region and moderate pain in the right and left knee as reported. region as reported.

Patient No: 9, Age: 68 yrs, Sex: F

A.P. views show mild degree of A.P. & Lateral views show early degenerative Show senile demineralisation of the bones Show senile demineralisation of the lumbo-

demineralisation of the bones around both the lumbar spondylosis -- particularly at L2-L3 & L3- around both knee joints, with advanced back- sacral vertebrae, with back-ground ground degenerative osteo-arthroses – degenerative lumbar spondylosis -- knee joints, with back-ground degenerative L4 levels- along with obliteration of normal lordosis particularly in the medial tibio-femoral particularly at L1 - L2, L3 - L4 & L5 - S1 levels. osteo-arthroses on both sides --particularly in of lumbar spines. No bony pathology is shown in compartments on both sides. Markedly exaggerated normal lordosis of the medial tibio-femoral compartments – and the sacro-iliac articulation on either side. lumbar spines, along with mild scoliosis -- bilateral genu varum as well. having its convexity towards left side -- are also evident. No bony pathology is shown in Figure 17: Represents there is a degenerative changes in both the knee joints the sacro-iliac articulation on either side. as well as lumbar region but the patient complains massive pain in the right Figure 20: Represents there is a degenerative changes in both the knee knee joint and very much pain in left knee joint and there is no sensation of pain joints as well as lumbar region but the patient complains massive pain in the in the limber region as reported. right knee joint and moderate pain in left knee joint and there is no sensation of pain in lumbar region as reported.

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• Age group of (51-60) years: Patient No: 10, Age: 67 yrs, Sex: F total patients 150 (38%)—male: 40 (27%) and female: 110 (73%) • Age group of (61-70) years: total patients 139 (35%)—male: 40 (29%) and female: 99 (71%) • Age group of 71->80 years: total patients 55 (14%)—male: 45(82%) and female: 10 (18%)

Show early degenerative osteo-arthroses in Show markedly exaggerated normal lordosis of Sensation of pain reporting scale both knee joints -- particularly in the medial lumbar spines,along with early back-ground compartments, and relatively more markedly degenerative lumbar spondylosis -- particularly During the course of examination of patients, the author has on the right side -- along with mild bilateral at L1-L2 & L3-L4 levels. No bony pathology is genu varum. shown in the sacro-iliac articulation on either noticed that the patients were instantly reporting pain as extremely side. painful (which the author termed as ‘A’ in the present study of sensation Figure 21: Represents there is a degenerative changes in both the knee of pain reporting scale) or very painful (which the author termed as ‘B’) joints as well as lumbar region but the patient complains massive pain in the left knee joint and very much pain in the right knee joint and there is in the areas where the intensity of the pain was much higher among the no sensation of pain in the lumbar region as reported. three joints such as right knee joint, left knee joint and lumbar region. After further queries the patients reported the less pain sensation areas among the three joint areas as ‘moderately painful’ (which the

Patient No: 11, Age: 72 yrs, Sex: F author termed as ‘C’) or ‘slightly painful’ (which the author termed as ‘D’) or ‘no pain’ (which the author termed as ‘E’) in the present study of sensation of pain reporting scale. Usually, on the basis of above mentioned pain sensation reporting, X-rays of particular regions, (either in right knee joint or left knee joint or both or L.S spine region) were taken to confirm the patients’ statements of sensitivity of pain and determine whether any degenerative changes or any other condition to

trigger pain have occurred.

Show mild degree of demineralisation of the bones around both knee joints, with advanced Show old healed compression For the purpose of quantifying the sensation of pain reporting fracture,with anterior wedging of the back-ground osteo-arthroses in the medial in right knee joint, left knee joint and lumbar region, the author has tibio-femoral compartments on both sides, body of L2 vertebra. Advanced back- and mild bilateral genu varum as well. ground degenerative lumbar established a simple sensation of pain reporting scale as, ‘A’ which spondylosis -- particularly at L1-L2, L3-L4 and L4-L5 -- along with implies extremely painful, ‘B’ which implies very painful, ‘C’ which exaggerated normal lordosis of lumbar implies moderately painful and ‘D’ which implies slightly painful spines are also shown .No bony pathology is seen in the sacro-iliac and ‘E’ which implies no pain. Normally patients suffering extremely articulation on either side. painful and very painful conditions reported to the clinic for check- Figure 22: Represents there is a degenerative changes in both the knee joints ups and treatment thereon. For the purpose of the study, the sensation as well as lumbar region but the patient complains massive pain in the right knee of pain reporting scale for 395 patients of different age group of (40- joint and moderate pain in the left knee joint but there is no sensation of pain in the lumbar region as reported. 50), (51-60), (61-70) and (71->80) years excluding the patients in the control group given in Table 1A. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC Index) Patient No: 12, Age: 71 yrs, Sex: M 90 patients (36 males and 54 females) were taken in control group out of 485 patients and rest 395 patients in different age groups of 40-50, 51-60, 61-70, 71->80 years were calculated separately for all males and females for all the parameters in percentage as shown in the WOMAC Index. The mean and standard deviation values are given in Table 2F. Statistical analysis

Show mild degree of demineralisation of the Show significant demineralisation of the Statistical analysis was done by using software (Graph Pad Prism, bones around both knee joints,with early back- lumbo - sacral vertebrae,with partial collapse Version, 5.0) for student-t test to determine significant values at P<0.05 ground osteo-arthroses on both sides -- and anterion wedging of the bodies of L1 and level along with R (Pearson correlation coefficient) values to determine particularly in the medial compartments -- L2 vertebrae. Marked narrowing of the and mild genu varum on the right side. intervertebral space between L5-S1, along strong and weak correlation among two variables for measuring with small osteophytic lipping from their different parameters of osteoarthritic patients’ for age group of 40 – bodies are shown -- suggestive of disc lesion. No bony pathology is shown in the sacro-iliac 50, 51 – 60, 61 – 70 and 71->80 years separately for right and left legs articulation on either side. compared to control group (40->80) of subjects. The comparisons were

Figure 23: Represents there is a degenerative changes in both the knee joints made for males and females separately in case of individual groups. as well as lumbar region but the patient complains massive pain in the lumbar All the data were considered and expressed at statistically significant region and moderate pain in the left knee joint but there is no sensation of pain (P<0.05) level. in the right knee joint as reported. First and foremost, the author has tried to evaluate the pain intensity

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Extremely Painful (A) Very Painful (B) Moderately Painful (C ) Slightly Painful (D) No Pain (E)

Right 3 15.0% 2 10% 6 30% 4 20% 5 25%

Left 5 25.0% 3 15% 5 25% 1 5% 6 30%

Male (n=20) Lumbar 5 25.0% 2 10% 3 15% 3 15% 7 35%

Right 4 12.9% 1 3.20% 8 25.8% 6 19.4% 12 38.7%

(40-50) years (N= 51) Left 8 25.8% 6 19.4% 5 16.1% 2 6.5% 10 32.2%

Female (n= 31) Lumbar 7 22.6% 5 16.1% 6 19.4% 5 16.1% 8 25.8%

Right 5 12.5% 4 10% 6 15% 4 10% 21 52.5%

Left 12 30.0% 8 20% 7 17.5% 3 7.5% 10 25%

Male (n=40) Lumbar 7 17.5% 4 10% 6 15% 5 12.5% 18 45%

Right 15 13.6% 7 6.4% 12 10.9% 11 10.0% 65 59.1%

Left 30 27.3% 16 14.5% 8 7.3% 7 6.4% 49 44.5% (51-60) years (N= 150)

Lumbar 32 29.1% 10 9.1% 18 16.4% 12 10.9% 38 34.5% Female (n= 110)

Right 6 15.0% 2 5% 8 20% 4 10% 20 50%

Left 14 35.0% 11 27.5% 4 10% 1 2.5% 10 25%

Male (n=40) Lumbar 5 12.5% 2 5% 10 25% 8 20% 15 37.5%

Right 10 10.1% 8 8.10% 12 12.1% 11 11.1% 58 58.6%

Left 34 34.3% 10 10.1% 8 8.1% 6 6.1% 41 41.4% (61-70) years (N= 139)

Female (n=99) Lumbar 28 28.3% 9 9.1% 11 11.1% 13 13.1% 38 38.4%

Right 4 8.9% 3 6.7% 11 24.4% 3 6.7% 24 53.3%

Left 8 17.8% 6 13.3% 10 22.2% 7 15.6% 14 31.1%

Male (n=45) Lumbar 16 35.5% 8 17.8% 2 4.4% 3 6.7% 16 35.6%

Right 1 10.0% 1 10.0% 3 30% 1 10% 4 40%

Left 3 30.0% 1 10% 2 20% 1 10% 3 30% (71- >=80) years (N= 55)

Female (n=10) Lumbar 2 20.0% 2 20% 1 10% 1 10% 4 40%

Sensation of pain reporting scale: A= Extremely painful, B= Very painful, C= Moderately painful, D= Slightly painful, E = No pain

Table 1A: The sensation of pain reporting scale of 395 patients having degenerative changes on knee joints and lumbar regions of age groups (40-50) years, (51-60) years, (61-70) years and (71->80) years irrespective of sex, body weight, lifestyle and ethnic barriers.

Page 7 of 11 with the visual analogue scale (VAS) (15), but the main deterrent, the age groups of 40-50 years were more affected (73%) with compared to author found, was in putting the dot at the right places on 100 mm other age groups. It was also observed the age groups of 71->80 years in long line, which represented the pain intensity in communicating the the male were more affected than the other groups of 51-60 and 61-70 intensity of pain on the right knee joint, left knee joint and lumbar years. region, by articulating extremely painful (A) or very painful (B) or In Tables 2A– 2E, average values of various measurement parameters moderately painful (C) or slightly painful (D) or no pain (E) was more viz. knee gaps between the short head of biceps femoris and the surface precise. The new sensation of pain reporting scale has established as a of the bed (in cm), diameter of calf muscles (in cm), diameter of thigh sure method of assessing the intensity of pain in this study (Table 1A). muscles (in cm), diameter of group of muscles connected with the knee Age groups wise percentage analysis of pain scale for males and joints, 4 cm above the patella (in cm), diameter of group of muscles females patients as per Table 1B as follows: connected with the knee joints, 4 cm below the patella (in cm) of 485 subjects were observed through these suitable techniques to identify Age group of 40-50 years: osteoarthritis in different age groups of patients’ (40 – 50, 51 – 60, 61 • Females were reporting to the clinic for treatment of pain – 70 and 71 and above), when compared to control groups of subjects more than the male patients by 22%. of age groups (40 - >80) for right and left legs. The comparisons were made on males and females groups of patients’ versus control groups. • Equal percentage of male and female patients were reporting for right knee joint pain. Measurements of knee gaps between the short head of biceps femoris and the surface of the bed for both the knee joints were differed • 11% more female patients were reporting for left knee joint as given in Table 2A. The reasons for not touching the back of the pain than male patients. knee joints on the bed was due to the cumulative effects of muscular • 11% more female patients were reporting for pain in lumbar wasting of vastus lateralis, vastus medialis, iliotibial tract, Inflammation region than male patients. of popliteal regions, stiffness of rectus femoris, inflammation over the connective joint muscles such as sartorius, gracilis, semimembranosus, Age group of 51-60 years: semtendinosus on the medial part of knee joint and rigidness • Females were reporting to the clinic for treatment of pain (calcification) of the movement of the patella etc. This happens due more than the male patients by 46%. to prolonged use of knee supports, hyaluronic acid injections or corticosteroidal injections or arthrocentesis (joint fluid aspiration) • 8% more female patients were reporting for right knee joint used for quick diminishing of pain and inflammation and such other pain than male patients. reasons. • 17% more female patients were reporting for left knee joint In case of knee gaps between the short head of biceps femoris pain than male patients. and the surface of the bed for both the knee joints, all the data for • 21% more female patients were reporting for pain in lumbar patients’ group were observed at increasing values at higher significant (P<0.001) level for both males and females groups when compared to region than male patients. control groups and R values were observed within the range of 87% - Age group of 61-70 years: 96%, which had strong correlation between experimental and control groups. • Females were reporting to the clinic for treatment of pain more than the male patients by 42%. Measurements of diameter of group of calf muscles for both the knee joints were found to be different from each other in Table 2B. Although • 7% more female patients were reporting for right knee joint some of the patients reported any pain either in the knee joints or pain than male patients. lumbar region. It was observed that the mismatched differences of the • 14% more female patients were reporting for left knee joint diameter of calf muscles were cumulative effects of muscular wasting of pain than male patients. gastrocnemius muscles due to prolonged use of knee supports or such other reasons. To be noted that calf muscles are very important for the • 21% more female patients were reporting for pain in lumbar alignment of spinal vertebrae. Slight difference of diameters between region than male patients. the two calf muscles of two legs can trigger compression in the lumbar Age group of 71->80 years: vertebrae. • Males were reporting to the clinic for treatment of pain more In case of diameter of calf muscles, it was observed from all the data than the female patients by 64%. for patients’, an increasing trend in all males of age groups of 40-50 and 51-60 years at highly significant (P<0.001) and R values had weak to • 9% more male patients were reporting for right knee joint strong correlation within the range of 28% - 82%, but the age groups of pain than female patients. 61-70 and 71->80 years, the data were increased without significance, • 18% more male patients were reporting for left knee joint while in female groups, it was observed significant decreasing trend pain than female patients. (P<0.05 and P<0.01) for age groups of 61-70 and 71->80 years and age groups of 40-50 and 51-60 years were found no significant changes. • 37% more male patients were reporting for pain in lumbar region than female patients. Measurements of diameter of thigh muscles were different from each other as shown in Table 2C. Although some of the patients were It was noticed from the Table 1B, that the subjects were more not reported any pain neither in the lumbar region nor one of the knee susceptible to pain in left knee joint than right knee joint. In case of joints. During measurement of the thighs, it was noticed that unequal degenerative changes in the lumbar region, it was observed that the differences in diameter of both the thigh muscles were the cumulative

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(40-50) yrs / N=51 (51-60) yrs / N=150 (61-70) yrs / N=139 (71 -> 80) yrs / N=55

Male Female M (f) F (f) M (f) F (f) M (f) F (f) N=20 (39%) N=31 (61%) N=40 (27%) N=110 (73%) N=40 (29%) N=99 (71%) N=45 (82%) N= 10 (18%) Right Knee joint 5 (10%) 5 (10%) 9 (6%) 22 (14%) 8 (6%) 18 (13%) 7 (13%) 2 (4%) Left Knee joint 8 (16%) 14 (27%) 20 (14%) 46 (31%) 25 (18%) 44 (32%) 14 (25%) 4 (7%) Lumber region 7 (13%) 12 (24%) 11 (7%) 42 (28%) 7 (5%) 37 (26%) 24 (44%) 4 (7%)

Table 1B: Statistical analysis of male and female patients different age groups reporting to the clinic for treatment of pain in right knee joint or left knee joint or lumbar region as per sensation of pain reporting scale combined with A and B categories.

CONTROL (40- > 80) (N (40-50) years (N=51) (51-60) years (N=150) (61-70)years (N=139) 71 ->80 years (N=55) =90) Mean (SE) Mean (SE) Mean (SE) Mean (SE) Mean (SE)

M= 36 (40%) F= 54 (60%) M=20 (39%) F=31 (61%) M=40 (27%) F=110 (73%) M=40 (29%) F=99 (71%) M=45 (82%) F=10 (18%) Right leg 2.64 (0.04) 2.5 (0.07) 5.29 (0.15) 5.60 (0.15) 5.65 (0.09) 5.89 (0.06) 7.10 (0.20) 6.18 (0.10) 5.68 (0.16) 5.80 (0.08) Left leg 2.64 (0.04) 2.5 (0.07) 5.30 (0.2) 5.74 (0.20) 5.47 (0.08) 5.77 (0.09) 6.67 (0.12) 6.08 (0.07) 5.40 (0.15) 5.40 (0.20) p-value (Rt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 2A p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 r-value (Rt) 0.91 0.9 0.96 0.94 0.95 0.89 0.89 0.92 r-value (Lt) 0.91 0.91 0.96 0.9 0.96 0.93 0.87 0.9 Right leg 34.08 (0.36) 35.85 (0.52) 40.38 (0.50) 35.52 (0.60) 36.00 (0.66) 36.28 (0.26) 34.96 (0.48) 34.38 (0.33) 34.56 (0.60) 33.40 (0.98) Left leg 34.08 (0.36) 35.85 (0.52) 40.55 (0.40) 35.34 (0.60) 35.95 (0.61) 36.46 (0.30) 34.45 (0.34) 34.63 (0.35) 34.44 (0.60) 33.50 (1.22) p-value (Rt) P<0.001 P = 0.342 P<0.05 P = 0.210 P = 0.08 P<0.01 P = 0.26 P<0.05 2B p-value (Lt) P<0.0001 P = 0.300 P<0.05 P = 0.130 P<0.01 P<0.05 P = 0.31 P<0.05 r-value (Rt) 0.82 0.04 0.28 0.06 0.17 0.2 0.07 0.24 r-value (Lt) 0.84 0.07 0.28 0.09 0.32 0.17 0.05 0.22 Right leg 45.21 (0.83) 55.09 (0.52) 52.48 (0.70) 50.84 (0.77) 49.35 (0.76) 52.68 (0.38) 46.96 (0.54) 52.20 (0.60) 46.74 (1.10) 50.00 (1.63) Left leg 45.21 (0.83) 55.09 (0.52) 52.30 (0.83) 51.05 (0.78) 49.60 (0.76) 52.96 (0.39) 47.33 (0.50) 52.48 (0.60) 46.59 (1.11) 48.60 (1.50) p-value (Rt) P<0.001 P<0.001 P<0.01 P<0.01 P<0.05 P<0.01 P = 0.14 P<0.01 p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.01 P<0.05 P<0.05 P = 0.20 P<0.001 r-value (Rt) 0.62 0.46 0.39 0.28 0.2 0.26 0.12 0.42

2C r-value (Lt) 0.6 0.43 0.45 0.24 0.24 0.22 0.1 0.52 Right leg 39.86 (0.55) 43.56 (0.7) 43.43 (0.61) 43.52 (0.63) 41.13 (0.76) 43.86 (0.42) 41.74 (0.44) 45.08 (0.50) 42.55 (1.12) 42.90 (1.40) Left leg 39.86 (0.55) 43.56 (0.7) 42.75 (0.75) 43.52 (0.51) 40.63 (0.70) 44.76 (0.42) 41.74 (0.44) 45.53 (0.50) 42.55 (1.12) 41.60 (1.50) p-value (Rt) P<0.001 P = 0.48 P = 0.09 P = 0.05 P<0.05 P<0.05 P<0.05 P = 0.35 p-value (Lt) P<0.01 P = 0.48 P = 0.20 P = 0.06 P<0.05 P<0.05 P<0.05 p = 0.13 r-value (Rt) 0.49 0.0008 0.15 0.13 0.3 0.14 0.26 0.05

2D r-value (Lt) 0.39 0.0009 0.1 0.12 0.3 0.19 0.26 0.14 Right leg 34.96 (0.40) 36.48 (0.41) 37.48 (0.46) 35.10 (0.45) 34.33 (0.51) 36.49 (0.25) 33.99 (0.35) 35.70 (0.30) 35.41 (0.63) 33.60 (0.65) Left leg 34.96 (0.40) 36.48 (0.41) 37.20 (0.43) 35.06 (0.38) 33.55 (0.50) 36.40 (0.27) 33.79 (0.29) 35.73 (0.32) 35.31 (0.72) 32.60 (0.65) p-value (Rt) P<0.01 P<0.05 P = 0.16 P = 0.5 P<0.05 P = 0.06 P = 0.30 P<0.05 2E p-value (Lt) P<0.01 P<0.05 P<0.05 P =0.45 P<0.05 P = 0.08 P = 0.32 P<0.001 r-value (Rt) 0.4 0.23 0.1 0.0004 0.18 0.12 0.07 0.35 r-value (Lt) 0.36 0.25 0.23 0.01 0.23 0.11 0.05 0.44 WOMAC

2F INDEX 16.05 (2.87) 16.28 (2.89) 82.82 (5.21) 82.33 (5.17) 82.22 (5.13) 82.89 (4.84) 82.24 (4.98) 83.37 (4.95) 82.06 (5.21) 84.17 (4.76) [MEAN (S.D)] Table 2: Measurement of knee gaps between the short head of biceps femoris and the surface of the bed (2A), diameter of group of calf muscles (2B), diameter of group of thigh muscles (2C), diameters of group of muscles connected with knee joints, 4 cm above the patella (2D), diameters of group of muscles connected with knee joints, 4 cm below the patella (2E) and WOMAC Index (2F) and their statistical analysis of 485 patients of age group (40 - >80) years having degenerative changes of both the knee joints and the lumbar region irrespective of age, sex, body weight, life style and ethnic barriers. effects of muscular wasting / muscular bulging in the posterior part about the sensation of severe or mild pain only in the lumbar region of the thighs such as rectus femoris, vastus lateralis, vastus medialis, or in one of the knee joints although degenerative changes both in the sartorius (part of the originated area), semitendinosus, long head of lumbar region and knee joints were found during the physical and biceps femoris, semimembranosus, adductor magnus in particular. radiological observations. Moreover the nerve root of semimembranosus and semitendinosus are In case of diameter of thigh muscles, it was observed that data sciatic nerve (tibial, L5, S1, S2,) originating from the tuberosity of the for all age groups of males were increased significantly (P<0.05 and ischium and inserting to tibia (pes anserinus). The patients complained P<0.01) except the age group of 71 ->80 while in females all the values

Page 9 of 11 were decreased significantly (P<0.05, P<0.01 and P<0.001) in all age and common peroneal nerve for short head, semimembranosus and groups when compared to control groups. semitendinosus (nerve root is sciatic nerve [tibial L5, S1, S2 ] for both the muscles). Gracilis (nerve root is anterior branch of obturator), Measurements of diameter of group of muscles connected with sartorius (nerve root is femoral nerve), popliteus (nerve root is tibial knee joint, 4 cm above the patella were differed from each other’s as nerve) and gastrocnemius (nerve root is tibial nerve from the sciatic, given in Table 2D. It was observed that the mismatched differences of specifically nerve root S – S ). Degeneration was simultaneously diameters in the knee joints were the cumulative effects of muscular 1 2 occurred in both the knee joints and lumbar region whether the wasting, inflammation, effusion or blood clotting due to engorgement pain were felt or not during the compression of the sciatic nerve. of saphenous vein. Because the four muscles namely sartorius, gracilis, Degeneration in the lumbar region had also occurred. This is proved semitendinosus and semimembranosus were all inserting to tibia from the radiological reports of both the knee joints and lumbar region (pes anserinus) and 90% of the patients suffering from osteoarthritis shown in the figures [12-23]. on knee joints were reported the acute pain on the connecting area of the above mentioned four muscles in the medial part of the knee. The author already established with the help of the phytotherapeutic Moreover, radiological reports reflected the degenerative changes that treatment protocol normal flexions of knee joints in supine, prone and simultaneously occur in the lumbar region and in both the knee joints standing positions made them symmetrical and brought them back to irrespective of whether severe pain was felt by the patient either in the normal limits to (140°- 145°), (130°- 135°) and (130 - 135°) respectively lumbar region or knee joints. and at the same time rectification of total degenerative changes on both the knee joints and lumbar region were removed as evident by In case of diameter of group of muscles connected with the knee pathological and radiological reports [8]. joints, 4 cm above the patella, it was found an increasing trend of statistically significant (P<0.05, P<0.01 and P<0.001) data for males Another important parameters, in case of measurements of knee of all age groups except the age group of 51-60 years while in females flexion in supine, prone and standing positions both in males and only age group of 61-70 showed significant (P<0.05) but rest of the age females were decreased with highly significant (P<0.001) value and R groups were not observed significant data. values had strong correlation ranges between 81% - 97%, 60% - 96% and 71% - 99% respectively for both right and left legs. These were Measurements of diameter of group of muscles connected with knee observed in all age groups when compared to control groups. joint, 4 cm below the patella were different from each other as given in Table 2E. Although some of the patients were not reported any pain Measurements of knee extensions were different from each other simultaneously in the lumbar region and both the knee joints. Usually, as given in Table 3D – 3F. Although some of the patients were not they reported of severe pain either in the lumbar region or any of the reported any severe pain simultaneously in the lumbar region and both knee joints. It was observed that mismatched differences of diameter of the knee joints. It was observed that angle of extensions in supine, prone the areas below the knee joint were the cumulative effect of muscular and standing positions of different patients were widely different. The wasting, inflammation, effusion or blood clotting on the anterior, muscles responsible for knee extension rectus femoris and medialis, posterior, lateral and medial parts of lower leg the tibialis anterior, vastus lateralis, vastus intermedius and rectus femoris and all inserting extensor hallucis longus and digitorum longus, gastrocnemius, achilles to patella via the quadriceps tendon and tibial tuberosity via the patellar tendon, flexor digitorum longus, flexor hallucis longus, fibularis longus ligament and the nerve roots of all the muscles are femoral nerve. The and brevis soleus etc were badly affected during degenerative changes degenerative changes were occurred simultaneously on both the knee occur in both the knee joints and lumbar regions. joints and lumbar region but severe pain felt only in one knee joint or both the knee joints. The degenerative changes were dipicted in the In case of diameter of group of muscles connected with the knee figures [12-23]. joints, 4 cm below the patella, it was observed that in males values increased (P<0.01) and decreased (P<0.05) significantly of the age The author already established with the help of the phytotherapeutic groups of 40-50 and 61-70 years while in females, decreased significantly treatment protocol normal extensions of knee joints in supine, prone in the age groups of 40-50 (P<0.05) and 71 ->80 (P<0.001) respectively and standing positions made them symmetrical and brought them back when compared to control group. in normal limits to (0° - 10°) each and at the same time rectification of total degenerative changes of both the knee joints and lumbar region The author has already established that symmetry between both legs were removed as supported by pathological and radiological reports can be achieved with the help of phytotherapeutic treatment protocol [8]. as evident from the anatomical measurement, which tallied with the control group figures. At the same time the removal of compression In case of measurements of knee extension in supine, prone and in the lumbar vertebrae regions as well as significant opening up of standing positions both in males and females were increased with joint spaces along with marked reduction the genu verum on both knee highly significant (P<0.001) value and R values had strong correlation joints were achieved [8]. ranges between 79% - 99%, 61% - 98% and 51% - 96% respectively for both right and left legs. These were observed in all age groups when Measurements of knee flexions were found to be different from each compared to control groups. other as given in table Table 3A – 3C. Although some of the patients were not reported any severe pain simultaneously in the lumbar region Patients were also clinically examined. C-reactive protein- C.R.P and both the knee joints. It was observed that mismatched differences [12], muscle creatine phosphokianse – C.P.K (13) and aldolase (14) of angle of flexions in supine, prone and standing positions of different are three clinical markers which increase in their activities during patients were widely different. The two main actions of knee joint are inflammation. The author already established with the help of flexion and extension with the ability to rotate slightly Most of the phytotherapeutic treatment protocol [8] these increase in activities muscles that move these joints located in the thighs with the exception of above parameters are decreased to normal level. The values of of the gastrocnemius and popliteus. The muscles responsible for knee biochemical parameters were higher in relation to the maximum limit flexions are biceps femoris - nerve root is tibial nerve for long head prescribed (Table 4).

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CONTROL (40- > 80) (N =90) (40-50) years (N=51) Mean (51-60) years (N=150) Mean (61-70) years (N=139) 71->80 years (N=55) Mean Mean (SE) (SE) (SE) Mean (SE) (SE)

M= 36 (40%) F= 54 (60%) M=20 (39%) F=31 (61%) M=40 (27%) F=110 (73%) M=40 (29%) F=99 (71%) M=45 (82%) F=10 (18%) Right leg 140.1 (0.08) 144.0 (0.15) 123.2 (0.80) 115.8 (1.18) 122.1 (1.13) 117.5 (0.74) 112.5 (1.50) 104.9 (1.72) 118.5 (1.06) 121.4 (1.5) Left leg 140.1 (0.08) 144.0 (0.15) 122.1 (0.98) 113.2 (1.39) 125.6 (0.44) 118.1 (0.63) 114.5 (1.50) 98.04 (2.84) 120.2 (0.91) 121.6 (1.8) p-value (Rt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 3A p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 r-value (Rt) 0.97 0.91 0.87 0.9 0.9 0.81 0.9 0.97 r-value (Lt) 0.96 0.95 0.96 0.91 0.88 0.7 0.91 0.96 Right leg 136.8 (0.72) 137.2 (0.42) 120.0 (0.83) 107.1 (2.11) 118.9 (1.30) 110.1 (0.86) 104.9 (1.50) 93.32 (2.66) 97.36 (2.22) 110.0 (0.82) Left leg 136.8 (0.72) 137.2 (0.42) 119.3 (1.03) 117.0 (3.83) 121.4 (1.10) 111.3 (0.80) 102.2 (2.47) 89.87 (2.72) 97.42 (2.82) 110.8 (0.33) p-value (Rt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 3B p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 r-value (Rt) 0.89 0.89 0.81 0.86 0.91 0.7 0.86 0.96 r-value (Lt) 0.89 0.6 0.8 0.86 0.83 0.72 0.81 0.96 Right leg 139.7 (0.12) 137.4 (0.25) 100.6 (2.41) 92.71 (1.37) 106.2 (2.25) 94.47 (1.65) 92.73 (0.74) 88.16 (2.96) 90.33 (1.96) 95.40 (4.25) Left leg 139.7 (0.12) 137.4 (0.25) 97.0 (2.72) 90.19 (1.46) 106.9 (2.01) 97.39 (1.11) 93.25 (1.44) 82.86 (3.22) 94.22 (2.34) 98.00 (3.27) p-value (Rt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 3C p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 r-value (Rt) 0.95 0.98 0.85 0.82 0.99 0.72 0.93 0.94 r-value (Lt) 0.94 0.98 0.87 0.89 0.96 0.71 0.89 0.96 Right leg 9.81 (0.07) 9.76 (0.09) 15.35 (0.26) 16.81 (0.73) 16.10 (0.10) 16.42 (0.12) 18.08 (0.21) 16.21 (0.15) 15.93 (0.17) 15.60 (0.16) Left leg 9.81 (0.07) 9.76 (0.09) 15.85 (0.27) 17.23 (0.84) 15.60 (0.11) 16.28 (0.17) 17.15 (0.14) 16.28 (0.11) 15.60 (0.13) 15.4 (0.16) p-value (Rt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 3D p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 r-value (Rt) 0.96 0.81 0.99 0.94 0.97 0.92 0.96 0.96 r-value (Lt) 0.96 0.79 0.98 0.9 0.98 0.95 0.97 0.95 Right leg 9.81 (0.07) 9.81 (0.07) 15.15 (0.08) 17.68 (1.36) 15.30 (0.13) 15.63 (0.12) 16.98 (0.20) 15.76 (0.14) 15.60 (0.26) 15.40 (0.16) Left leg 9.81 (0.07) 9.81 (0.07) 15.35 (0.26) 16.55 (0.61) 15.30 (0.13) 15.75 (0.16) 16.05 (0.13) 15.71 (0.14) 16.11 (0.19) 14.40 (0.16) p-value (Rt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 3E p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 r-value (Rt) 0.83 0.61 0.97 0.91 0.97 0.91 0.91 0.98 r-value (Lt) 0.96 0.82 0.97 0.87 0.98 0.9 0.95 0.98 Right leg 9.81 (0.07) 9.76 (0.09) 13.35 (0.26) 15.13 (0.38) 14.65 (0.14) 13.65 (0.35) 16.23 (0.23) 14.86 (0.16) 15.53 (0.19) 14.40 (0.16) Left leg 9.76 (0.09) 14.35 (0.26) 15.29 (0.46) 14.75 (0.16) 13.63 (0.35) 15.30 (0.16) 14.71 (0.14) 15.60 (0.19) 14.2 (0.49) p-value (Rt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 3F p-value (Lt) P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 r-value (Rt) 0.91 0.88 0.96 0.51 0.95 0.87 0.95 0.93 r-value (Lt) 0.94 0.85 0.95 0.51 0.96 0.9 0.94 0.89 Table 3: Measurement of knee flexion in supine position (3A), in prone position (3B), in standing position (3C), knee extension in supine position (3D), in prone position (3E), in standing position (3F) and their statistical analysis of 485 patients of age group (40 - >80) years having degenerative changes of both the knee joints and the lumbar region irrespective of age, sex, body weight, life style and ethnic barrier. Conclusion to compression of disc space. But we have found in our examinations that disc compression at the lumbar region always lead to degenerative Recent advances in technology, selective and efficacious medicines changes in the knee joints, whether pain is felt or not. At the same time have enabled us to understand the complex processes involved in degenerative tissue damage in the knee region is always marked by the generation of arthritic pain. But some questions still remain compression of the disc at the lumbar region, whether pain is felt or not. unanswered like, why is some arthritic pain episodic, whereas other patients complain of chronic and persistent joint pain? [9]. This is An important aspect of the present study was to assure that all because, the mechanoreceptors located in the skin, are sensitive to the measurements parameters are suitable tool to identify the painful disease like osteoarthritis. Many researchers have been documented pressure as well as stretching (light to moderate). They send messages that knee pain, stiffness, unable to movements and body fitness are the through the neurons and the central nervous system which interprets common diagnostic factors for osteoarthritis [16-18]. It was found that these messages as tactile sensations. But when the mechanical pressure pain score evaluation and functional disability as parameters studied by on a body tissue becomes so strong that they threaten its integrity or researchers and also biochemical and hematological parameters during actually damages it then the pain receptors, also known as nocieptors, treatment [19-23] but no one has attempted this easy screening tool in take over. It may be certain expressions of nociceptors are required the present work for osteoarthritis patients. Further research is required to feel pain [10, 11]. We have observed that knee joint pain may not emphasizing with these parameters during treatment of osteoarthritis be felt when there are degenerative changes in the lumbar region due to analysis the recovering result by the treatment.

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(40-50) years (N=51) Mean (61-70) years (N=139) Mean (51-60) years (N=150) Mean (SD) 71->80 years (N=55) Mean (SD) (SD) (SD) M=20 (39%) F=31 (61%) M=40 (27%) F=110 (73%) M=40 (29%) F=99 (71%) M=45 (82%) F=10 (18%)

CRP (mg/l) 2.15 (0.64) 8.75 (5.30) 6.75 (3.61) 9.35 (10.25) 2.85 (2.33) 12.75 (9.54) 4.25 (2.76) 4.80 (2.40)

4 CPK (µ/l) 203 (224.86) 59.00 (11.31) 289.50 (311.83) 55.50 (9.19) 107.50 (50.20) 183.00 (5.66) 121.50 (53.03) 197.50 (112.43) Aldolase (µ/l) 8.55 (0.15) 7.34 (0.77) 9.66 (2.21) 4.08 (0.16) 6.54 (0.690) 8.50 (0.57) 7.40 (0.99) 7.65 (0.64) Normal Range: C-Reactive Protien (with Titra method): upto 6mg/l, CPK (UV Konetic, DGKC & IFCC) : 29.00 - 133.00 (µ/l) Aldolase (Enzymatic with TIM & GDH) : 0.3 - 7.60 (µ/l) Table 4: The biochemical parameters of 395 patients (145 males and 250 females) having degenerative changes/reduction of joint spaces between the bones/ vertebrae.

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This article was originally published in a special issue, Physiology handled by Editor(s). Dr. Robert A Walker, New York Chiropractic College, USA.

Anat Physiol Physiology ISSN:2161-0940 Physiol, an open access journal