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All you knee is love — and RICE
Essentially being a weight-bearing joint, the knee goes through wear and tear, causing pain. Hence knee problems are quite common.
Obesity, lack of muscle strength and having a history of injuries could increase the chances of a person getting knee pain. “Women seem to suffer more than men because of excessive activity in the knee-joint area as they attend to their household chores while standing,” a doctor tells Happiest Health.
But doctors say the pain can be delayed by making lifestyle changes such as exercising regularly and reducing weight. Avoiding squatting and sitting cross-legged also helps.
It was six years ago when Meena B, a homemaker from Bengaluru, started developing knee pain. The pain affected the life of the 64-year-old considerably. She started facing hurdles while doing her daily chores. Doctors told Meena that she had developed knee pain due to her age, prolonged periods of standing while working and the wear and tear of her knee joint.
“Due to knee pain, my work pace reduced. I couldn’t stand for more than 30 minutes at one stretch. I needed to rest or sit for at least ten minutes before restarting the work I had left midway,” Meena tells Happiest Health.
Explaining the reasons behind knee pain, Dr Naresh Shetty, a Bengaluru-based orthopaedic, president of Quess Health Care in Bengaluru, says, “Knee joint is made of bone, cartilage, ligaments, muscles and tendons and together they help in its movement. When any of these structures are damaged, people get knee pain. The common causes are degenerative arthritis (age-related), rheumatoid arthritis (inflammatory), ligament injury and fracture.”
Symptoms
Pain, stiffness, swelling and immobility are the common symptoms of knee pain, informs Dr Shetty. He says that climbing, squatting or bending the knee could worsen the symptoms.
“Redness, warmness, weakness, instability, popping and cracking noises and the inability to fully straighten the knee are the other symptoms of knee pain,” says Dr Girish A, senior resident, department of orthopaedics, Subbaiah Medical College and Hospital in Shivamogga, Karnataka.
Risk factors
Both Dr Girish and Dr Shetty say that obesity, lack of muscle strength, previous injuries, deformed knees and inflammatory or infected knees could increase the chances of a person getting knee pain.
Diagnosis
Diagnosis of knee pain is made based on patient history, physical examination and investigation. “A few conditions are more likely to occur in individuals with certain characteristics. For example, primary osteoarthritis is more frequent in older adults (degeneration of articular cartilage). However, injuries, infection or inflammation cause secondary osteoarthritis,” says Dr Shetty.
“Physical examination helps in looking out for any swelling, fluid collection or instability of the joint. Blood investigations and imaging help in confirming the clinical diagnosis. X-rays, CT scans or MRIs are needed for identifying any damage or abnormalities.”
Treatment
Dr Girish says that knee pain can be treated through physiotherapy like moist heat, isometric quadriceps exercise and hamstring strengthening exercises.
“The isometric quadriceps and hamstring strengthening exercises include tightening of thigh muscles with a rolled towel under the knee and straight leg raising,” says Dr J V Srinivas, lead consultant, orthopaedics and joint surgery, Aster RV hospital, Bengaluru.
To fix the structural damage, surgery is also a solution. “Meanwhile, surgery should not be the first choice. Knee pain can be also treated through complementary therapies as some people find relief using massage, biofeedback (a method that provides feedback regarding the electrical activity of the muscle which helps in assisting the individual to increase and decrease the tension developed in the muscle), relaxation, meditation, acupuncture and yoga,” says Dr Shetty.
“Knee problems are very common. Knee is essentially a weight-bearing joint and it goes through wear and tear and this causes pain,” says Dr Shetty. “Knee pain is more prevalent among obese persons and people with a history of injuries. Women seem to suffer more than men because of excessive activity in the knee joint area as they attend to their household chores while standing,” he adds.
Dr Shetty says that knee pain can be delayed by making lifestyle changes like including regular exercise and reducing weight.
Doctors’ recommendations to alleviate knee pain
- Weight loss: The knee is a weight-bearing joint and thus losing weight becomes important to reduce its burden. Body Mass Index (BMI) should be maintained between the range of 18.5-25 kg/m2.
- Being smart about exercises and playing sport: Isometric quadriceps exercise (knee strengthening exercise) and playing any kind of sport is helpful.
Low impact workouts like swimming and walking and light strength training workouts are also recommended. - Avoid squatting and sitting cross-legged: These activities aggravate knee pain and can lead to arthritic changes (inflammation and breakdown of joints).
- Using RICE (Rest, Ice, Compression and Elevation) therapy helps in reducing swelling and pain. It is useful for all acute injuries like sprains and bruises.
- Walking aids: Walking aids assist in walking and improving mobility. It helps reduce pain, decrease the risk of falling and increase confidence while walking. Examples of walking aids are crutches, cane, walkers etc.
- Corrective footwear: These are designed to address the trouble areas of the foot. It can help reduce pressure in diabetic feet and correct the arches in flat feet. It can also be used for club foot and uneven limbs.
- Food supplements: Food supplements like Omega 3 fatty acids like fish oil, turmeric and Vitamin D help reduce knee pain.
- Local application of medicines can also reduce pain and inflammation. It could be in the form of gel, cream, ointment or spray.
- Using mild pain killers (only if advised by doctors) and avoiding strenuous activities.
After her knee pain became unbearable, Meena decided to see a doctor. “I did not go to a doctor during the initial days of knee pain. I was taking pain killers, wearing knee socks and massaging my knees with coconut oil, castor oil and mustard oil.” Later, she went to an orthopaedic who suggested surgery. However, Meena’s life did not stop, thanks to RICE therapy.
Why phones are a pain in the neck
The forward head posture while holding phones and other devices is quite common; especially when We discuss how this poor posture causes pain in the neck and upper back, and the ways in which it can be prevented or managed.
Spend lots of time with your favourite gadgets? Chances are you will become familiar with ‘text neck’ or ‘tech neck’ one day in the future.
To take a common example, while texting on the phone one tends to bend the head forward and look down. Now, this places about 22 to 27 kg of force on the neck, which cannot withstand such pressure for prolonged periods. The head weighs from 4.5 to 5.5kg.
“Text neck is posture formed by leaning forward for prolonged periods,” said Dr Umesh Srikantha, consultant, neurosurgery, head of spine services, Aster CMI Hospital, Bengaluru. “It is caused by repetitive strain and possible injury to the cervical spine where excessive texting or mobile device use is believed to be the primary cause.”
The rising popularity of media devices such as smartphones and computers, frequent users often exhibit incorrect posture. “Such users bend forward to watch or text, leading to forward head posture (FHP), which is a poor habitual neck posture,” said Dr Roshan Kumar Jaiswal, senior orthopaedic surgeon, Kamineni Hospitals, Hyderabad.
Symptoms of text neck
“The common symptoms of text neck are pain in the neck, upper back and shoulders, FHP and rounded shoulders (shoulder position that has moved forward from the body’s ideal alignment), tightness and reduced mobility in the neck, upper back and shoulders, eyestrain, headache and increased pain [caused by] neck flexion (movement of lowering chin down to the chest),” said Dr Srikantha.
“Text neck is a term coined by a chiropractor and is not officially included in the medical diagnosis classification,” said Dr Srikantha. “That doesn’t mean it’s not real. As of now, several terms like ‘postural neck pain’ or ‘chronic cervical strain’ or ‘cervical myofascial pain’ are used by medical practitioners to describe the same condition.”
Dr Jaiswal said text neck is not a disease but an occupational hazard that can occur due to several reasons or work-related activities which require prolonged forward bending of the neck.
Self-care: Text neck treatment
“One must use self-care measures to relieve neck pain by taking short breaks and performing exercises that target the neck, chest and upper-back muscles. Mild-to-moderate neck pain usually responds well to self-care within two or three weeks. If the pain persists, it is recommended to consult a doctor for further evaluation.
“Imaging tests such as X-rays, CT scans and MRIs are usually recommended to get a better picture of the cause of your neck pain. Based on your condition, your doctor may prescribe medicines or suggest therapies and other surgical procedures,” said Dr Srikantha.
Pain relief is the main goal in acute cases, according to Dr Jaiswal. “It can be achieved by regular neck movements like rotations and side bending, restoring function to upper trapezius and serratus, chin-tuck exercises, ice or heat packs, and massage,” he said.
Upper trapezius is the smallest section of the trapezius (either of a pair of muscles moving the head and shoulder blade). It starts at the base of the neck and extends just across the tops of the shoulders. It helps to lift your arms, rotate, extend, turn and tilt your neck and head. Serratus is any of the three muscles of the thorax that arises from the ribs and vertebrae.
Exercises to beat text neck
Dr Srikantha recommended a couple of neck-strengthening exercises to fix text neck. For example, one can place the feet on the ground and sit straight and relax the arms. “Put your right hand on your head and tilt your head on the right and hold it for 30 secs,” he said. “Follow the same using your left hand.
“In the same straight position, place two fingers on your chin. Tuck your chin and gently pull your head back. Use your fingers to keep your chin tucked to your chest. Hold it for a few seconds and relax. Repeat two to three sets, 10 times each.”
Dr Jaiswal said one can prevent text neck by avoiding excessive usage of media devices and taking frequent breaks while using the devices. “One should position the device in such a manner that it reduces stresses both on the head/neck and the upper extremities (upper arm, forearm and hand),” he said. “In order to avoid getting text neck, one should minimize high repetitions of movements such as prolonged typing or swiping, and not hold large or heavy devices in one hand for long duration.”
Dr Srikantha said while using the phone or working, people should bring the screen to eye level, so their head is not slouched forward or too high. And it is always good to take breaks and spend some time away from the phone and computer.
The not-so-ordinary period pain
Many women brush off menstrual pains as something inevitable. When they beco me debilitating, it is time to get a doctor’s opinion as they could be an indicator of a serious condition called endometriosis.
Endometriosis is a painful condition when tissue similar to endometrium — the tissue that lines the uterus — starts growing outside the uterine cavity, causing acute menstrual and abdominal pain. Though it is common, not many people are aware of it, resulting in a delay in diagnosis. The precise reasons for a person developing endometriosis are still not clear and much research is ongoing to better understand the condition.
According to the World Health Organisation (WHO), endometriosis affects approximately 10 per cent of women and girls aged between 15 and 44, which accounts for roughly 190 million globally. Around 50 per cent of infertile women are found to have the condition.
“The endometrium-like tissue can grow on the ovaries, bowels and in the pelvic region,” says Dr Suhasini Inamdar, consultant, obstetrician and gynaecologist, Motherhood hospital, Bengaluru. “This misplaced tissue gets affected due to the hormonal changes during the menstrual cycle and becomes inflamed and painful. As it grows, thickens and breaks down, it has nowhere to go and gets trapped in the pelvis. This leads to scar formations, irritation, severe pain during periods and fertility issues.”
Dr Inamdar says endometriosis tends to present symptoms that women might brush off as the normal ones occurring during periods. “This can result in diagnostic delay,” she says. “Women should seek the help of their doctors who will be able to do the proper tests to determine if they have endometriosis.”
She says that according to the data provided by the Endometriosis Society of India, the disorder is quite common and affects as many as 2.5 crore women in the country alone. “The majority of the cases we see are from states like Orissa, West Bengal, Andhra Pradesh, Karnataka, Tamil Nadu and Kerala,” she says. “The disease can impact any woman who has started her menstrual cycle, irrespective of her age. However, women in their 30s and 40s are the most affected.”
Dr Pallavi Prasad, fertility consultant at NOVA IVF Fertility, Bengaluru, says that endometriosis is a common reproductive problem. She says the most frequent symptoms of the condition are chronic lower abdominal (pelvic) pain, pain during menstruation (dysmenorrhoea), pain during intercourse (dyspareunia) and infertility. Other symptoms include backache and stomach problems like diarrhoea, constipation, bloating and nausea, primarily during periods.
“It is recommended that women who experience the symptoms of endometriosis should visit a gynaecologist to better understand the symptoms, causes and possible treatments,” says Dr Prasad. “The doctor might perform a few tests to confirm it. Women who have endometriosis should immediately get professional help as the symptoms of the disease worsen over time and start interfering with their daily routine. After examining the patient’s reproductive and medical history, other tests such as pelvic exam, ultrasound, laparoscopy and biopsy are conducted.”
Four stages
Dr Prasad says the stages of endometriosis are based on the spread of the tissue and its depth.
- Stage 1 (minimal): At this stage, there will only be a few small implants or spots. There is little — and in many cases, no — scar tissue at all. Usually, the endometriotic spots will be found in the abdomen, on the peritoneal surface. (Peritoneum is the membrane that lines the abdominal cavity and the organs of the abdomen.)
- Stage 2 (mild): Here the implants will be deeper. There may also be some scar tissue.
- Stage 3 (moderate): At this point, there may be small cysts developing on one or both the ovaries and there will be many deep implants. The organs that could be affected are the ovaries, rectum and uterus. The anatomy of the pelvic organs can be significantly distorted.
- Stage 4 (severe): This is the stage where the condition is most widespread. The person affected may have deep implants and thick adhesions. There will also be large cysts on one or both the ovaries. At this stage, the organs outside the pelvic cavity may also be affected like bowels, appendix and diaphragm.
Is prevention possible?
Dr Inamdar says that at present, there is no known way to prevent endometriosis. “It is a chronic condition that tends to be recurrent and has no permanent cure,” she says. “The solution lies in increasing awareness among women so they can get it diagnosed early, which will enable them to manage the symptoms. Timely treatment can aid in slowing or halting the progression of the condition. The treatments include medications and constant scans to keep a check on its progress.”
Dr Prasad also makes the same observation and says that there is no way to prevent endometriosis. According to her, early diagnosis and lifestyle changes can help manage and reduce the painful symptoms associated with the condition.
“If the symptoms are too severe, your healthcare provider may recommend pain medications or other anti-inflammatory drugs to help ease the pain,” she says. “Treatments for endometriosis usually lower the oestrogen levels and increase the progesterone levels to create a suitable hormonal environment. Hormone therapy, including oral contraceptives, may also be recommended to manage the symptoms. The surgical technique used to treat endometriosis is laparoscopy, in which the doctor removes the endometriosis tissue without harming the healthy tissue. Patients with endometriosis are advised to plan their conception early, as it is a progressive disorder and reduces the fertility potential of a woman. Endometriosis, if detected early, is manageable.”
It can be recurring
Recalling a case study, Dr Inamdar says that one of her patients, aged 36, suffering from endometriosis had to undergo laparoscopic surgeries three times because the endometrial cysts kept reappearing and this affected not only the person’s fertility, but also her emotional health.
“This was a recurrent case of endometriosis where the expert had to tell the person to keep coming back for gynaecological checks as her condition had to be managed properly,” she says. “The person is still under observation and if the cysts subside, she will plan her pregnancy. In such cases, the risk of infertility rises as the ovarian tissue is being eaten up by the cyst. During surgical procedures, the cyst is removed, without causing any damage to the ovaries. Post-endometriosis, it can be difficult to conceive naturally.”
How to keep RA under control
There is no cure for rheumatoid arthritis, but treatment and precautionary measures can restrict its impact and lessen the risk of joint damage
Those who have experienced a painful swelling in their joints due to rheumatoid arthritis will tell you that it is nothing less than hair-raising. The pain, the swelling and the continuous discomfort due to the disease is a lifelong agony since there is no cure for it. Still, precautionary measures and treatment can lessen the risk of joint damage and restrict the impact of the condition.
Rheumatologists describe rheumatoid arthritis as an autoimmune and chronic inflammatory disorder that affects the joints. “It commonly hits the hands, knees and ankles,” Dr Chethana D, consultant, rheumatology, Aster CMI Hospital, Bengaluru, told Happiest Health. “It occurs when the immune system mistakenly attacks a person’s own body tissues. Rheumatoid arthritis affects the lining of the joints which can cause painful swelling and can lead to bone erosion and joint deformity.”
According to Dr Shweta Singhai, consultant, rheumatology, Sakra World Hospital, Bengaluru, rheumatoid arthritis can impact the eyes, skin, lungs, heart and nervous system too.
Who can be affected?
Rheumatoid arthritis (like most diseases and conditions) does not discriminate on the basis of a person’s age or gender.
“It can affect any age group — from children to elders,” said Dr Singhai. “Both men and women are vulnerable to it. However, rheumatoid arthritis affects women more than men in a ratio of 9:1. The age which is mostly affected is 20 to 40 years. It can also be seen in new mothers just a few weeks after childbirth. Many women in post-menopausal period also develop rheumatoid arthritis.”
Family history, smoking and being overweight can increase the risk of getting the disease.
“People born with specific genes such as HLA (human leukocyte antigen) class II genotypes and those with a family history of rheumatoid arthritis are more likely to develop it,” said Dr Chethana. “Smokers and overweight people are at the risk of developing rheumatoid arthritis.”
Symptoms and causes
Doctors told Happiest Health that the symptoms differ from person to person. In the initial phase, the disease affects the smaller joints (fingers and toes). Later, the symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. These include:
- Pain, swelling, stiffness and tenderness in more than one joint
- Joint stiffness that is usually worse in the mornings and after inactivity
- Pain and stiffness in the same joints on both sides of your body
- Fatigue, weakness, fever, loss of appetite, etc.
Best practices and diet
Having a healthy diet and maintaining a healthy weight are the common suggestions given by rheumatologists to keep the disease at bay.
The British Dietetic Association (BDA) advises people living with rheumatoid arthritis to maintain a healthy weight and change the type of fat in their diet to help them get some relief from the pain and swelling. The BDA, which represents the whole of the dietetic workforce in the UK, advises people to eat more oily fish, fish oils, follow a Mediterranean diet and eat iron-rich and calcium-rich foods.
“There’s no way to prevent rheumatoid arthritis,” Dr Chethana said. “But there are certain things a person can do to minimize the risk. Healthy diet, exercise, smoking cessation and good mental health are all keys to control it.”
She said self-care plays an important role in managing rheumatoid arthritis and in easing the pain and fatigue associated with it. “It is important to consume a balanced and nutritious diet consisting of the recommended amounts of all the food items to maintain a healthy weight,” she said.
“We should try to be physically active. Instead of using a lift, we should take the stairs and walk around our homes to keep ourselves physically active. One can also try hot and cold treatments. Both heat pads and warm baths work well for soothing stiff joints and tired muscles. However, cold pads and cold baths are best for acute pain and swollen joints. Body and joint massages help to reduce pain, relax sore muscles and ease stress and anxiety. We should take proper rest and try to de-stress ourselves by doing meditation, deep breathing, yoga, etc.”
People should also maintain good oral hygiene. “Gum and periodontal disease can make a person more prone to rheumatoid arthritis,” said Dr Singhai. She said there is “no particular anti-rheumatoid arthritis diet”.
“However, an anti-inflammatory diet is advisable,” she said. “This includes eating more vegetarian or vegan diets, including more polyunsaturated fatty acid, oleic acid and synbiotics in diet plans.
“Addition of spices like turmeric and ginger, seasonal fruits and probiotic yogurt are good sources of natural antioxidants and deliver anti-inflammatory effects. Herbs like ashwagandha and green tea and basil (tulsi) tea are beneficial too. The patient should avoid any processed food, high salt, oils, butter, sugar and animal products. Dietary supplements like vitamin D, cod liver oil and multivitamins can also help in managing rheumatoid arthritis.”
This is one disease where doctors recommend medication after diagnosis to restrict any kind of permanent damages left by rheumatoid arthritis.
Other health issues
Described by the medical fraternity as a “complex disease”, rheumatoid arthritis often brings other health issues along with it.
According to an article published on the website ScienceDirect, some diseases like cardiovascular disease, infections or lymphoma co-occur more frequently in a person living with rheumatoid arthritis.
Don't be a slouch potato at work
Desk workers, especially those who work on electronic devices, are usually sedentary (waking behaviour where little energy is spent while sitting, reclining or lying down). Musculoskeletal pain and disorders are among the most prevalent occupational problems among them.
Today, especially in the post-pandemic world, our work, travel and social lives encourage sitting or standing for prolonged periods. Everyone knows how painful poor posture can be. Slouching for too long, stirring too much or driving in peak traffic — any of these can send a pulsing pain through the body.
Poor work posture also damages the muscles and bones, which has long-term effects. Of these, musculoskeletal (muscles and bones) pain is felt first.
“MSDs [musculoskeletal disorders] are usually multifactorial,” says Dr Deepak Sharan, the dean of RECOUP Neuromusculoskeletal Rehabilitation Centre, Bengaluru. “Several factors related to the nature of work, ergonomics, environmental factors, psychosocial stressors and individual predisposition together play a role. Adopting hazardous postures is only one of the several risk factors.”
Desk workers, especially those who work on computers or other devices, are usually sedentary (waking behaviour where little energy is spent while sitting, reclining or lying down). Musculoskeletal symptoms and disorders are, therefore, among the most prevalent occupational problems. About 40 per cent of the general population report musculoskeletal pain annually.
“Sitting is the new smoking,” says Dr Prathap Addageethala, director of Atlas Chiropractic and Wellness, Bengaluru. “Back in the day, smoking was in vogue. Then ground-breaking research said that smoking causes cancer. Now, people still smoke but they’re aware of the risks.”
What’s good posture?
While sitting, support for the back is essential. The back must press against the support (the chair’s backrest) to sit upright. The shoulders shouldn’t bend forward and should be rolled back, with the shoulder blades down. The arms should be bent at a 74-to-90-degree angle with the chin parallel to the ground. The legs should be slightly apart and the feet must be flat on the ground.
“The goal is to intervene before your behaviour becomes a part of your adaptation,” says Addageethala, who is a doctor of chiropractic. “Your spine adapts over time, so if you neglect poor posture for a long period of time, your bones degenerate faster and your poor posture gets locked in from a structural standpoint.”
Keeping a pillow to support the lower back can help maintain the curve in the spine. Get up and walk around at regular intervals to prevent muscle fatigue.
Identifying the signs
A tell-tale sign of your poor posture is discomfort or pain in the neck, shoulders, upper back or lower back. You may also experience tingling, numbness or weakness. Stiffness and cramping may also occur, affecting your grip and flexibility.
Shilpa, who joined an IT major in Bengaluru during the lockdown, feels that it is difficult to pay attention to posture when she is absorbed in her work. “Working from home was a new concept,” says Shilpa, who is in her thirties. “Initially, I sat wherever and however I wanted. But I couldn’t sustain working like that. Then, I bought a chair and made sure to work at my dedicated workstation.”
In a study on the risk of musculoskeletal symptoms in computer users, 7-30 per cent of the cohort displayed symptoms in the lower back and over 50 per cent showed symptoms in the upper extremities (upper arm, forearm, wrist and hand).
“I had knee pain for a while, so I wasn’t comfortable sitting on the chair,” says Shilpa. “I stretched my legs and worked on my bed. But then my shoulders went for a toss.”
Hunching for extended periods of time will strain the muscles in your back and abdomen, reducing blood supply and can cause pain. A forward bend with the head to the front may strain the lower spinal discs causing herniation (problems in the discs or cushions between the vertebrae).
“If you sit in a position for a long period that’s comfortable but not ergonomically sound for your spine, your body will adapt to that position,” says Dr Addageethala. “If you can’t identify these postural issues, you may already be in that default mode where your body is trying to save energy and you’re going to be in that slouched position to start with. Digging yourself out of that becomes difficult, but it can be improved.”
Repeated movements such as clicking on a mouse or keyboard work can lead to tight muscles or tissue inflammation, which in turn causes compression of the nerves.
Maintaining awkward postures while sitting on a chair, positioning the wrist while typing or holding something for a long time can affect the cervical and lumbar spine joints, which are more likely to strain when the spine is in a prolonged awkward position. Sitting in a chair with a slumped posture can strain the ligaments and cause stiffness and inflammation in the joints.
Another common source of pain is applying pressure or repeatedly straining a certain region over a period — this could be the wrists while gripping the mouse or the elbows while typing. Keeping the mouse far from the keyboard will result in maintaining the awkward position which puts pressure on the wrists, shoulders and neck.
Dr Sharan says “workstyle” (how a worker responds behaviourally, cognitively and physiologically to stressful work demands) may help explain the link between ergonomic and psychosocial factors in MSD. “Of the 4,500 IT professionals we studied, 22 per cent were at a high risk of adverse workstyle,” he says. “Social reactivity, lack of breaks and deadlines/pressure were significantly correlated with pain and loss of productivity.”
The following tips may help reduce muscle stiffness and pain while managing your posture better:
- Taking frequent breaks and walking/moving around during them
- Alternating between sitting and standing
- Resting the legs on a footrest
- Exercising the neck (rotating, bending to the sides, chin-tucks), shoulders (rolling, shrugging) and waist (bending to the side, front and back)
- Using a pillow to support the lower back while sitting
One Response
I read about knee pain which was useful and of course known. At the age of 74 I do play golf stopped the TM (diagnosed as early OA due to aging) and only doing stationary cycling and do not take any pain killer. What is the effect of cycling?