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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 10
| Issue : 4 | Page : 256-264 |
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Low back pain: the riveting history with unexplored ancient Indian knowledge
Piyush Verma, Shiwangi Kanaujia, Ashutosh K Pathak
Department of Rachana Sharir, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P, India
| Date of Submission | 09-Sep-2022 |
| Date of Decision | 09-Dec-2022 |
| Date of Acceptance | 10-Dec-2022 |
| Date of Web Publication | 31-Dec-2022 |
Correspondence Address:
Dr. Ashutosh K Pathak
Department of Rachana Sharir, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jism.jism_75_22
Introduction: Low back pain affects 70–85% of the adult population at some point in life. In total 45–75% of patients continue to experience pain after 12 months of onset. Low back pain is a major health hazard in today’s technological era. The history of low back pain is as ancient as human civilization. There are pieces of evidence of low back pain and sciatica in the past era, which was a problematic concern for the population of that time. There was a practical approach of different cultures toward the low back and sciatic pain at that time. The rich history of Indian medicine guides us to the classic developments and thoughts of that era. Aims and Objectives: This study aims to illuminate descriptions and understandings of low back pain from previous historical reviews as well as fill gaps in previous reviews that ignored the hidden knowledge of low back pain from ancient Indian literature. Materials and Methods: Here published scientific articles in reputed journals regarding the historical background of low back pain, sciatica, and lumbar radiculopathy have been reviewed from PubMed, Google Scholar, Scopus, and so on, and low back pain conditions from ayurveda classics have been extracted and conceptual understanding to low back pain by ancient Indian ayurvedic scholars have been revealed. The lacunae in previous reviews of missing the knowledge of ancient Indian ayurvedic texts have been tried to fill by this work. Observations and Results: The review showed that the understanding of various conditions associated with low back pain such as katishoola, katigraha, gridhrasi, trikshoola, trikvedna, and so on. and its pathophysiology was well developed in ancient Indian culture. Conclusion: Numerous earlier studies on low back and sciatic pain have overlooked the historical significance of the Indian subcontinent. The existing information must therefore be revealed along with these crucial descriptions. The world’s focus will be directed toward ayurvedic medicines and low back pain management solutions when the concepts of ayurveda are revealed historically. As a result, this article will aid in promoting the traditional Ayurvedic medical method. Keywords: Gridhrasi, Katigraha, Katishoola, low back pain, sciatica
How to cite this article:
Verma P, Kanaujia S, Pathak AK. Low back pain: the riveting history with unexplored ancient Indian knowledge. J Indian Sys Medicine 2022;10:256-64 |
| Introduction | |  |
The complaint of low back pain is a widespread health issue as it affects every individual at some point of time in their life, the pain may be up to the extent that it limits their daily routine, and in most cases, medical advice is needed. Low back pain is progressively burdening society as previously it was mostly found in persons above 40’s, but nowadays, due to various factors, it can be also found in young and adolescents. Low back pain may be categorized into acute or chronic, where acute low back pain can be defined as the pain with a duration of 6–12 weeks occurring between the costal angles and gluteal folds. The pain may radiate down one or both legs (sciatica).[1] Usually, low back pain resolves over time, but 31% of subjects may not fully recover within 6 months. These unrecovered cases may be considered to be suffering from chronic low back pain.[2] The variation in annual prevalence of low back pain is from 9.9 to 25%, with a point prevalence of 4.6–13.4% and a lifetime prevalence of 1.2–43%.[3] Commonly men are affected in their 40s whereas females are in their 50s and 60s.[4],[5] In the Indian population, the prevalence of low back pain varies between 6.2% (in the general population) and 92% (in construction workers) with a lifetime prevalence of 60–90% and an annual incidence of 5%.[6],[7] Being one the most prevalent musculoskeletal disorder, low back pain affects 70–85% of the adult population at some point in life. In total 45–75% of patients continue to experience pain after 12 months of onset.[8],[9] Thus radicular low back pain is a major health hazard in today’s technological era. Various causes related to low back pain in different age groups have been identified today. Lumbar radiculopathy due to degenerative changes and herniation of the disc is the most common condition in the above 40 years age group. If sacral roots are also involved, then it is termed as lumbosacral radicular syndrome. These conditions affect lumbar and sacral spine root and present as radicular pain in one or more dermatomes corresponding to the nerve roots involved. The symptoms may manifest from low back pain to sciatica with numbness and weakness of the lower back and legs.[10]
The history of low back pain is as ancient as human civilization. There are pieces of evidence of low back pain and sciatica in the past era, which was a problematic concern for the population of that time. There was a practical approach of different cultures toward the low back and sciatic pain at that time. The rich history of Indian medicine guides us to the classic developments and thoughts of that era. Numerous earlier studies on low back and sciatic pain have overlooked the historical significance of the Indian subcontinent. The existing information must therefore be revealed along with these crucial descriptions.
Aims and Objectives
This study aims to illuminate descriptions and understandings of low back pain from previous historical reviews as well as fill gaps in previous reviews that ignored the hidden knowledge of low back pain from ancient Indian literature.
| Materials and Methods | | |
Here in this article published scientific articles in reputed journals regarding the historical background of low back pain, sciatica and lumbar radiculopathy have been reviewed from PubMed, Google Scholar, Scopus, and so on, and low back pain conditions from ayurveda classics have been extracted and conceptual understanding to low back pain by ancient Indian ayurvedic scholars have been revealed. The lacunae in previous reviews of low back pain have missed the knowledge of ancient Indian Ayurvedic texts. This work has attempted to fill those gaps.
| Review of Literature | | |
History of Low Back Pain and Sciatica Outside Indian Subcontinent
Ancient Egyptian, German and British
The earliest evidence of back pain outside the Indian subcontinent comes from an ancient Egyptian surgical text called Edwin Smith papyrus (named after Edwin Smith, who bought it in 1862). The Edwin Smith papyrus has been assumed to be of 1500 BC. The ending of this incomplete text accompanies the description of acute back strain (sprain in vertebrae of the spinal column).[11] Ancient Germans and Britishers believed this sudden attack of sciatica resulted from an attack by supernatural forces such as demons, witches, curses, and so on. This belief was reported by Sigerist[12], a historian and doctor of the 19th century. A similar view was persistent in the ancient Egyptian population who considered ‘junins’ or the devils as the cause of sciatica.[13]
The Greeks
A step ahead, the ancient Greeks considered some natural imbalance in the body as the cause of sciatica but confused sciatica with other clinical entities such as gout, and so on. The great Greek physician Hippocrates (460 BCE–375 BCE) related the season with the prevalence of diseases in which he believed that the period of summer and autumn were more associated with sciatica.[14],[15] He also believed that excessive horse riding in upper-class people results in a sexually weak population prone to disorders of joint swelling such as sciatica. He considered the spine as divine and believed it to be the site of the formation of sperm and the communication route to all other organs. Thus, sexual weakness was related to the development of spinal disorders, including sciatica.[16],[17],[18] He used the term ‘ischias’ for the pain around hips and thighs and described the sciatic pain as ‘ischiatic’ pain, which affects persons between 40 and 60 years of age and resolves spontaneously after a certain duration of 40 days. According to him, the localized pain to the hip carried a poor prognosis than the pain radiated to the foot.[19] Paul of Aegina or Paulus Aegineta (7th century), a famous Byzantine Greek physician, considered the thick humor present in the hip joint as the cause of sciatica. In chronic cases, he also hypothesized the burning of some areas of joints.[20]
The Romans
Octavia the Younger (69/66–11 BC), the sister of the first Roman Emperor, Augustus, and wife of famous roman general Mark Antony used a mixture of some herbs and oils to treat sciatica.[21] Aretaeus of Cappadocia (the early roman physician in the 1st century) had the idea of the intense pain of sciatica.[22] Another famous roman physician Caelius Aurelianus of Sicca (4th century), believed sciatica to be more frequent in middle-aged persons.[23] He described the nature and pattern of sciatic pain as strong, severe pain originating from the lower back and radiating into the buttocks, perineum, and even the popliteal fossa, calf, foot, and toes. Sensory disturbances, muscle wasting associated with the lower extremity, constipation, claudication, and postural difficulty during defecation were also observed by him in sciatica. Although he beautifully described the sciatic pain but there was some confusion about sciatica with osseous tuberculosis as he believed the involvement of some ‘humor’ or pus in this disease. The causative factors such as a sudden jerk, excessive digging and lifting of heavy objects, excessive sexual intercourse, and sexually active men who undergo termination of hemorrhoidal bleeding, were believed to be associated with sciatic pain by him.
The middle East
In ancient Hebrew scriptures (Genesis 32:25–32) (1450 BC–1400 BC) there is a story of Jacob who wrestled with gods or angels but lost due to injury in the hip joint or sciatic tendon, since then the consumption of animal’s nerve of that area (sciatic nerve or ligaments of that part) was considered unsuitable in this culture.[24] ‘Schigroma’ is the term used for sciatica in another Hebrew text, ‘Talmud’ (5th–6th century CE). Here instructions of rubbing fresh brine to the painful areas are given. Talmud also shows the procedure to remove the sciatic nerve from freshly slaughtered animals. The 11 Sciatic nerve was termed as irk ol-nasha in Arabic and gid-ha-nasks in the Hebrew language.[25] Outside the Indian subcontinent, bloodletting in sciatica was first instructed by an Assyrian Christian physician named Mesue (Ibn Masawaih, 777–857 CE) using the idea of Aelius Galenus or Galen (129–216 AD), who itself was a renowned physician, surgeon, and philosopher in the roman empire. Wrapping of the thigh and tibia four fingers above the ankle before bloodletting was described by an Egyptian Jewish physician named Isaac Judaeus (Ishaq ibn Sulaiman, c 850–ca. 932).[26] Serapion, a Syrian Christian Nestorian physician (9th century), practiced the procedure of bloodletting in the sciatica above the ankle.[27] A Persian polymath and one of the thinkers and writers of the Islamic golden age named Ibn Sina/Abu Ali Sina or Avicenna (as known in the west) (ca. 970–1037) advocated the use of meixaragl (picrotoxin) in sciatica.[28]
History of Low Back Pain and Sciatica in Indian Classics
The term Katishoola for low back pain
Katishoola is the term used in ayurvedic texts which resembles low back pain. The term ‘Kati’ used for lower back arises from the oldest language of human civilization, Sanskrit (4000–5000 BC). In an ancient text, Amarkosha ‘Kati’ has been related to the area of ‘Sroni’ or hip bone.[29] The meaning of Shoola (Ruja, Vyatha, Yama, or Ruk) is pain or discomfort.[30] Thus Katishoola is can be defined as the pain or disease in the lumbar region (Kati).[31]
Vedic period-(4000–1500 BC)
The earliest textual references of back pain in Indian literature can be traced back to the Vedic era (4000–1500 BC) where ‘Pristamaya’ term has been mentioned which is formed from two Sanskrit words- Prista meaning back and Amaya meaning disease. By combining these two means’ disease of back’.[32]
The ayurvedic literature
In Charaka Samhita (1000–200 BC) several terms were used in the literature for diseases of the back such as ‘Pristagraha’ and ‘Gridhrasi’. Pristagraha (formed from two Sanskrit words- Prista which means back and Graha which means stiffness combining both terms leads to the meaning as the stiffness of back region) and Gridhrasi (correlated to sciatica) has been categorized in Vataja-Nanatmaja-Vyadhi (diseases occurring mainly due to vitiated Vata-Dosha).[33] ‘Jangha-Uru-Trika-Prista-Roga-Sosha’ is a symptom mentioned by Acharya Charaka for Gudagata-Vata (vitiated Vata in Guda or anal region). Here this term means diseases (Roga) that involve the leg, thigh, hip, and back and cause emaciation (Sosha) of this region.[34]Gridhrasi is a disease that has been correlated with sciatica nowadays and was described as a Vata-Vyadhi (a disease that occurs due to vitiation of Vata-Dosha in Ayurveda).[35] The classic description starts with the eruption of pain first in the hip region followed by involvement of the lumbar region (Kati), back (Prista), thigh (Uru), knee (Janu), leg (Jangha), and feet (Pada). Stiffness (Stambha) and pulsatory sensation (Spandan) along the path may also accompany the pain in this disease.[36] A symptom Katinistoda (pricking pain in the lumbar region) was mentioned as a prodromal symptom of Vatarakta by Acharya Charaka in the 29th chapter of ChikitsaSthan.[37]Trikvedana is another term that means the pain of the hip region and has been mentioned as a symptom of pakvashayagat-Vata (vitiated Vata of Pakvashaya or lower digestive tract).[38]Kubjata (the deformed spine) is included under the symptom of Snayugat-Vata (vitiated Vata in Snayu or Musculo-fibrous and ligamentous structures) of the back.[39] Other terms for deformed back conditions that are mentioned in Charaka Samhita are Antarayam and Pristayam which were associated with some convulsive disorders in which the spine tends to bend in opposite directions.[40],[41]
In Bhel Samhita (1000 BC approx) Katishoola has been mentioned as one of the Vata-vyadhi (diseases caused due to Vata-Dosha) and ‘Kati-Prista-Gata-Vata’ has been given here which means painful conditions of the back and lumbar region.[42] Here complications of Panchkarma procedures specially Vamana and Virechana have been considered as the cause of Katishoola.[43]
In Susruta Samhita (1000 BC to 200 AD) Kativedana has been mentioned as a prodromal symptom of Bhagandara (Fistula-in-ano) and Vriddhi-Roga in Nidana-Sthan 3rd and 12th chapter, respectively.[44],[45] Like Charaka Samhita, in Susruta Samhita there is also the description of Gridhrasi in Nidan-Sthan 1st chapter where Acharya Susruta has beautifully described the radicular nature of the disease in the form of loss of motor functions in the region of the ankle (Pashni) and toes due to vitiation of Vata-Dosha.[46] He had also given the procedure of Siravedhan (bloodletting) in Gridhrasi (compared to sciatica) where he suggests puncturing the vein 4 Angula (measure of distance in finger breadth) above or below the knee joint for treatment.[47]
Other ayurvedic texts such as Harita Samhita (1000–1200 AD) named Katishoola as a symptom of Gridhrasi.[48] Kashyap Samhita (600 BC) has mentioned the causes of Katishoola for pediatric age in its Khilasthana. One of the causes of Katishoola as given by Kashyap is excessive walking.[49] Symptoms and ayurvedic pathogenesis of Katigraha and formulations for it have been given in Gadnigraha by Sodhala.[50]TrikShoola and Katigraha have been understood as two separate entities by Bhava Prakash. Trik has been referred to as the area of the joint of the spinal column and hip bones.[51] Terms such as Kati SandhigataVata, Kati Vata, and Trikshoola have been given by Yogaratnakar.[52] In Sharangdhar Samhita, Katishoola has been included under VatajNanatmajVikara.[53]
History of low back pain and sciatica in modern era
In the 17–18th century, low back pain was understood under the category of rheumatism in which ‘rheuma’ was a watery evil humor in the Greek language. This ‘rheuma’ was thought to be the cause of different types of joint pain. Lumbago or low back pain was described as a third form of Rheumatism by an English physician of the 16th century named Sydenham. The cause of rheumatism was assumed to be some exposure to cold and dampness.[54] In the 18th century, frequent railway travel was thought to be the cause of spine diseases and lumbago.[55] The first book on sciatica was written by Italian anatomist Domenico Cotugno (1736–1822) in 1764, thus it was also known as Cotugno’s Disease.[56] The evidence of intervertebral disc involvement in sciatica was first explained by Schmorl and Andrae in 1929.[57],[58] In 1934 at Massachusetts General Hospital (US) first case of ruptured intervertebral disc was operated and was documented in the New England Journal of Medicine. This was a great milestone achieved in the concept of the involvement of the intervertebral disc in lumbosacral pain.[59] The initial postulated concept that sciatic or lumbosacral pain occurs due to pressure on the lumbosacral nerve root, was first challenged by Kelly.[60] He proposed that the pain mechanism may be different from nerve root compression as nerve root compression would mainly cause loss of function. The concept of inflammatory reaction which arises because of intervertebral disc prolapse and causes sciatic pain was proposed by Lindahl and Rexed.[61] Xavier et al.[62] gave the hypothesis of pain mechanism in sciatica due to antidromic activation of nociceptors.[63]
| Observations and Results | | |
Low back pain has become a common clinical presentation in today’s era. It is a prevalent problem among persons above the age of 40 years as well as it also involves different age groups. It may be radiating or limited to the lumbosacral area. The radiating low back pain is called Lumbosacral radiculopathy, which can be described as back pain radiating to the legs and is very commonly sharp, burning, or electric in nature. Any compressive force or irritation along any point of the nerve can cause symptoms of lumbar radiculopathy.[64] The primary cause of lumbar radiculopathy is degenerative changes in lumbosacral vertebrae joints called degenerative spondyloarthropathies.[4] In these degenerative changes, the lumbosacral disc disorders comprise of 90% of cases of radicular low back pain which includes herniation and compression of the lumbosacral disc as proved by neuroradiological studies.[65],[66] Due to this herniation and compression of the lumbosacral disc, the dorsal root ganglia or dorsal roots of the lumbosacral region get adversely affected, causing spinal stenosis, and ultimately the symptoms of radicular low back pain emerge. In these symptoms, the most common complaint is the pain of the low back which is neuropathic in origin and is spontaneous and evoked type in nature[67],[68],[69] [Figure 1].
The history of low back and sciatica are very ancient; as different civilizations evolved, they described and managed the pain in their own way. Different concepts came into light in due course of time and gave way for the development of current methods to tackle the pain. In older times outside the Indian subcontinent, the root pathology of radicular low back pain and sciatica was very unclear. Rheumatism was confused with the sciatic pain that they believed to occur due to some defect in ‘humor’ or ‘pus’ present in joints and spine causing low back pain.
Inside the Indian subcontinent, the concept of low back pain evolved with the ancient science of Ayurveda. From most primitive Vedic literature to the later ayurvedic literature has descriptions of low back pain here and there [Table 1]. | Table 1: Prominent developments in history of low back pain and sciatica in sequence
Click here to view |
| Discussion | | |
The ayurvedic system of medicine gave the concept of three doshas namely Vata, Pitta, and Kapha which are constituents of the body as well as perform various functions. From ancient times in Indian literature, the Vata-Dosha has been considered as the most influencing Dosha among the three Doshas which initiates and regulates the other Doshas. Charaka has described Vata as ‘Vayustantrayantradhara’ which means it is a governing system of the body in itself and monitors all other functions. That’s why it has been related to the nervous system of our body and all our sensory and motor activities have been understood to be regulated by Vata-Dosha. The vitiated VataDosha has also been called to be responsible for pain.[70] The other doshas have different roles in the pathologies. Charaka has also given the etiological factors which vitiate the Vata-Dosha causing different Vata-vyadhis (diseases due to Vata). In this, the dietary factors as well as lifestyle and traumatic factors are mentioned.[71]
Today we know that in radicular lumbosacral pain the basic pathology lies in the nerve root compression due to disc bulging. This disc bulging cause nerve compression which is the cause for numbness, disturbances in motor functions, and pain. Although the emergence of pain involves some inflammatory processes with nerve compression and herniation. As here the primary pathology in radicular pain is related to nerves, so the basic concept of the involvement of Vata-Dosha by ancient ayurvedic experts remains unquestioned.
Apart from the sensation of pain Vata-Dosha has been said to be the main residing dosha in AsthiDhatu (bony tissue) by AstangHridaya by Vaghbhat in explaining Ashraya-AshrayiBhava. Here Vatais Ashrayiand bony tissue is Ashrya.[72] The Doshas (Ashraya) affect their residing tissue (Ashrayi) by increasing or decreasing. That is when Pitta or Kapha increases, they increase the residing tissue and vice versa but the opposite occurs in the case of Vata. So, an increase in Vata-Dosha will decrease the AsthiDhatu (bony tissue) and vice versa. Vata-Dosha has been said to be more prominent in old age, thus naturally occurring diseases of Vata occur in old age persons. This increase in Vata-Dosha gradually affects the quality of bony tissue by causing degenerative changes. Thus the ancient ayurvedic science clearly explains the degenerative pathology in the spine to be the root cause of radicular low back pain in old persons [Figure 2]. | Figure 2: Understanding the pathogenesis of low back pain in ayurvedic perspective
Click here to view |
Primitive Indian cultural texts and Ayurvedic texts mention various conditions of the back which indicated wide insight of the acharyas of that time. The early mention of Pristamaya in Vedas refers to the group of diseases of the back. Two major symptoms of lower back involving pain as described in Ayurveda are Katishoola and Gridhrasi. Katishoola was used broadly for the symptom of lower back pain. Whereas the description of Gridhrasi was very similar to sciatica-type radiating pain. The classical description of Gridhrasi in Charaka Samhita and Susruta Samhita shows that these ancient scholars were having the idea and knowledge of radicular pain involving a certain area and pattern of nerve distribution. Another condition in Ayurveda called Katigraha which was different from the above two descriptions was used for restricted movement of the lower back. Stambha or stiffness has been called as an integral part of Katigraha.[73] Apart from the above, the conditions such as Kubjata, Antarayam, and Bahirayam explained in ayurvedic texts give light to the deforming conditions of the spine and back. Here Antarayam and Bahirayam were associated with some convulsive pathologies whereas Kubjata was an anatomical defect that occurred because of vitiated Vata in Snayu (Musculo-fibrous structures or ligamentous structures). The term Trikvedna which was used in Charaka Samhita in reference to Pakvashayagat-Vata (vitiated Vata in Pakvashaya or lower digestive tract region) can be correlated to the referred pain felt at the back or lower back because of pathology in the abdominal or pelvic area). Another related term in Charaka Samhita namely Trikshoola is mentioned under the context of Aptarpana (therapeutic reduction in body mass).[74] The above conditions can be summarized in [Table 2]. | Table 2: Different terminologies for painful back conditions in ayurveda
Click here to view |
Many times these conditions are used interchangeably for one another as these different entities coexist. Broadly speaking, the acharyas had the concept of localized pain, radiating pain, conditions of restricting movements of lower back, deforming conditions, and radiating painful conditions of the back or lower back region as well. These all show the tremendous ancient understanding and approach of that time.
Besides these above descriptions, low back pain has been mentioned as a symptom or prodromal symptom in many diseases in ayurvedic texts. These can be summarized as follows dividing them into spinal and nonspinal pathologies [Table 3]. | Table 3: Pathological conditions associated with clinical features of painful lower back in ayurveda[75]
Click here to view |
Besides this, the ancient acharyas also explored treatment modalities for painful conditions of the back, such as Panchkarma procedures such as Virechana (therapeutic purgation), Basti (medicated and oil/fat enema), Purvakarma [Swedana (oleation) and Snehana (sudation)], Katibasti (localized external oil application in large quantity), and so on with the aim to normalize the vitiated Vata-Dosha, the root cause of any pain, so therapies that normalize Vata-Dosha were advised in these patients.[75] As described earlier Sushruta advised Siravedhana (bloodletting) in Gridhrasi (radicular low back pain/sciatica). Oral herbo-mineral preparations are indicated in these conditions along with these therapies. Nowadays, Marma Therapy (vital points stimulation) is being practiced by ayurveda clinicians in several musculoskeletal disorders based on the Marma science of ancient ayurvedic texts. These time-tested therapies based on ancient knowledge are cost-effective and may prove promising alternatives to mainstream therapies to tackle pain.
| Conclusion | | |
The issue of low back pain has become more prevalent in the modern day and is now impacting a sizable population. Low back pain, along with related afflictions such as sciatica, sacroiliitis, spondylitis, and so on, has a long history. Every culture has made contributions to the growth and comprehension of itself. The history of sciatica and low back pain is covered in a number of publications and articles written by western authors. Prior research, however, lacked a comprehension of and contribution to Ayurveda and traditional Indian medical culture. The ayurveda classics demonstrate that there was a significant understanding of different painful lower back diseases at that time, such as katishoola, katigraha, gridhrasi, trikshool, trikvedna, and so on.
Specific Need for this Review and Future Scope
The purpose of this article is to highlight the views and concepts from the Indian subcontinent that were still prevalent at the time and to give readers a better understanding of the history of low back pain. The world’s focus will be directed toward ayurvedic medicines and low back pain management solutions when the concepts of ayurveda are revealed historically. As a result, this article will aid in promoting the traditional Ayurvedic medical method. Ayurvedic specialists who desire to conduct additional research and practice in the area of low back pain and its related disorders can benefit from this review.
Financial Support and Sponsorship
The financial support is just the UGC fellowship of PhD (Research Entrance Test Fellowship [RET]) which is allotted to the Scholar by the BHU.
Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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