|Year : 2021 | Volume
| Issue : 2 | Page : 103-112
An observational study on the effect of individualised homoeopathic medicine administered based on totality of symptoms vis-à-vis personality in cases of osteoarthritis knee
N Rajeev Kumar1, N Harihara Iyer2
1 School of Behavioural Sciences, Mahatma Gandhi University, Kottayam, Kerala, India
2 Deparment of Organon of Medicine, Dr. Padiar Memorial Homoeopathic Medical College, Ernakulam, Kerala, India
|Date of Submission||09-Nov-2019|
|Date of Acceptance||02-Feb-2021|
|Date of Web Publication||29-Jun-2021|
N Harihara Iyer
Deparment of Organon of Medicine, Dr. Padiar Memorial Homoeopathic Medical College, Chottanikkara, Ernakulam, Kerala
Source of Support: None, Conflict of Interest: None
Background: Individualisation is the process of arriving at the image of the patient for the selection of remedy. The customary way of individualisation of the patient is through the construction of totality of symptoms. The little explored area in Homoeopathy is individualisation solely based on personality characteristics. Objective: The objective of this study was to compare the effect of individualised homoeopathic medicine administered based on totality of symptoms vis-à-vis personality in patients suffering from knee osteoarthritis. Methods: The observational study includes 60 clinically diagnosed cases of osteoarthritis knee, of which 30 cases were administered the homoeopathic medicine selected on the basis of totality of symptoms and thirty cases based on personality. Randomisation was done using computer-generated numbers. The personality of the patients was assessed through the 44-item Big-Five Inventory. A self-made tool, transcribing trait items to rubrics of the homoeopathic repertory, was prepared. The knee osteoarthritis scores on physical function, pain and patient global estimate in Routine Assessment of Patient Index Data 3 (RAPID3) sheet, before and after treatment, were compared. Results: The paired difference mean of RAPID3 in totality of symptom-based administration was 4.06 and for personality-based administration was 1.92 with a standard deviation of 3.91 and 3.29, respectively. The test result is statistically significant at 0.05 level (P < 0.05). Conclusion: Administration of individualised Homoeopathy medicine based on totality of symptoms is found to be more effective as compared to individualised Homoeopathy medicine based on personality amongst patients suffering from osteoarthritis knee.
Keywords: Big Five, individualised homoeopathy, osteoarthritis knee, personality, Routine Assessment of Patient Index Data 3, totality of symptoms
|How to cite this article:|
Kumar N R, Iyer N H. An observational study on the effect of individualised homoeopathic medicine administered based on totality of symptoms vis-à-vis personality in cases of osteoarthritis knee. Indian J Res Homoeopathy 2021;15:103-12
|How to cite this URL:|
Kumar N R, Iyer N H. An observational study on the effect of individualised homoeopathic medicine administered based on totality of symptoms vis-à-vis personality in cases of osteoarthritis knee. Indian J Res Homoeopathy [serial online] 2021 [cited 2022 Dec 2];15:103-12. Available from: https://www.ijrh.org/text.asp?2021/15/2/103/319614
| Introduction|| |
Individualisation is one of the fundamental principles of Homoeopathy. Different methods of analysis are in use to individualise a patient in Homoeopathy. The most prominent and commonly practised method of individualisation of a case is through the construction of totality of symptoms. Hahnemann has narrated individualisation based on characteristic totality in aphorism 147 and 153 of Organon of Medicine. The other method of individualisation suggested by Dr. Kent is based on the general symptoms. Hahnemann and Kent also have stressed the importance of mind symptoms in individualisation of the case. The statement of Dr. Kent confirms his views in this regard as he observes, 'It is the man who is sick and man consist of what he thinks and what he loves and there is nothing else in a man. Man is the will and understanding and the house in which he lives is his body'. Tyler and Weir opined that strong mental generals will rule out all other lesser marked symptoms. Dr. Richard Hughes pointed out that the final selection of a similar remedy should be based on individual similarity, especially in those diseases that affect every subject in their way. Thus, the views of Dr. Kent and Dr. Richard Hughes underline the same idea of Hahnemann as said in aphorism 5 of Organon that individualisation of the patient with the help of disposition is possible in Homoeopathy.
According to psychologists, personality is more or less a true representation of an individual. American psychological association defines, 'personality is the individual difference in the characteristic pattern of thinking, feeling and behaving'. In personality psychology, the domain that is more concentrating on thinking, feeling and resultant external behaviour to designate personality is the trait theory of personality. McCrae views 'Traits are characteristics that lead people to behave in a more or less distinctive and consistent way across situations'. These characters or traits are systematically arranged and categorised into different dimensions to designate the personality and individuality of a person. Personality psychologists now accept the five-dimensional concept as the most refined one amongst all trait concepts. The major dimensions used to designate personality in 'Big Five' are extraversion, agreeableness, conscientiousness, neuroticism and openness to experience. Psychologists have confirmed this fact that the five-factor model is the major structure underlying many existing personality inventories. Accordingly, the individualisation of a person is possible by assessing the dimensions of personality in an inventory.
Osteoarthritis is a disorder of diarthrodial joint that is characterised clinically by pain and functional limitation, radiographically by osteophytes and joint space narrowing, histopathologically by alteration in cartilage and subchondral bone. The epidemiological studies show that osteoarthritis affects people above the age of 50 years and largely female gender. It amounts to the global health burden by functional incapability and disability. It adds to global expenditure in the way of treatment cost and absenteeism from work. In a WHO study, it has been revealed that by the year 2050, 130 million will suffer from osteoarthritis worldwide, of whom 40 million will be disabled by the disease. Globally, knee osteoarthritis is the fourth significant cause of incapability in women and eighth in men. In India, approximately 45% of the population of over 65 years of age show symptoms of osteoarthritis. A study on women aged above 40 years in Kerala identified that 41.6% of people had symptoms of osteoarthritis knee, and amongst them, 66.2% had bilateral osteoarthritis. The diagnosis of osteoarthritis is confirmed on clinical symptoms alone or with clinical and radiographic findings. The main clinical symptoms include pain during and just after joint use; stiffness, especially rising from sitting; and buckling while walking. The major signs are crepitus, bony tenderness, bony enlargement, tenderness at medial ligament attachment and no palpable warmth on the affected joint.
The risk factors for the development of osteoarthritis include systemic, joint environment and joint overloading factors. Increasing age, female sex, heredity and race are the systemic risk factors. In females, the oestrogen deficiency during the menopausal age affects not only the bone and articular cartilage directly but also increases the chance of being obese that, in turn, will lead to an increase in joint overloading. The role of heredity is more seen in hand osteoarthritis compared to the knee. Indians are more prone to osteoarthritis knee than the Western people. The joint environment factors and joint overloading factors such as obesity, repeated overuse of the joint and increased bone density may lead to articular cartilage destruction and thereby the development of osteoarthritis.
Apart from the previously mentioned factors, the role of personality and psychosocial events as an accompaniment for the development of osteoarthritis has been extensively studied. Psycho-emotional stress has a contributory role in the initiation and aggravation of degenerative changes of osteoarthritis. A study identified that negative effect on personality was elevated along with disease activity of osteoarthritis. In-depth study reports are available on the possible relationship between personality dimension and osteoarthritis. Two major studies considering this point are the relationship between osteoarthritis and depression and the role of personality dimensions of Big Five in osteoarthritis patients. All these study reports reiterate that osteoarthritis is a disease of constitutional affection that affects every individual their way.
Homoeopathy is a therapeutic system which is erected on the strong foundation of Law of Similia, Similia similibus curentur, meaning let likes be treated by likes. Even though it is an established thought that Homoeopathy relies much on the mental and emotional state of the patient for the selection of medicine, the systematisation of mental and emotional symptoms in a prescribed pattern to suit to individualise a patient for the selection of drug has not formulated so far efficiently and prudently. Finer shades in personality studies show that personality is more or less a true representation of individuality. In Homoeopathy, individuality has arrived at a great extent through personality characteristics though not fully. Trait theory of personality assesses personality from the commonly speaking words (trait words) that represent the behaviour. The homoeopathic case taking demands the recording of the symptoms of the patient in their own words. Quoting Hahnemann, Dr. Stuart Close opined that the language of drugs in homoeopathic materia medica is common man's language. In this context, the attempt for linking the individualisation concept of Homoeopathy with the trait theory of personality is more or less possible as the determining criteria of individualisation in both methods are the verbal expressions and outward behaviour. It is learned from the literature searches that so far no valid studies are available on medicine selection based on personality alone.
Hence, the objective of the present study was to compare the effect of individualised homoeopathic medicine administered on the basis of totality of symptoms vis-à-vis personality in patients suffering from knee osteoarthritis.
| Methods|| |
Study design for this research study is a comparative, observational study.
Data collection was done between June 2017 and December 2018. The patients who continued the treatment protocol for 6 months after initial consultation were considered for final analysis of comparison.
Samples for the observational study were collected from the outpatient department of Dr. Padiar Memorial Homoeopathic Medical College, Chottanikkara, Ernakulam, Kerala. The study was conducted under the guidance of and support of School of Behavioural Sciences, Mahatma Gandhi University, Kottayam, Kerala.
A checklist of clinical diagnostic criteria for osteoarthritis by the American College of Rheumatology was used to screen the patients for the study.
The inclusion criteria were age above 40 years and persons strictly under the domain of clinical diagnostic criteria of the American College of Rheumatology. Patients who were having other rheumatic diseases such as rheumatoid arthritis and gout were excluded from the study. Patients who had a history of knee injury and who had undergone knee surgery were also exempted from the study group.
Sample size calculation was done based on a pilot study. The coefficient variation of that study was 14%. Then, the sample size for the present study was calculated on the formula n = (t2 / ∈2 × (C.V)2 = 31.36. It is rounded and fixed as 30 for each group. Here, t is taken as two and ∈ is taken as 0.05, assuming at 5% interval. Since the procedure started after explaining all the study protocols to the patient and the study duration was fixed, the dropout from the study was nil. The items of Big-Five were transcribed into Homoeopathic rubrics and its reliability measure is shown as [Annexure 1].
Sixty clinically diagnosed cases of osteoarthritis were selected for the final analysis of medicine selection of which thirty cases for individualisation based on totality of symptoms and thirty cases for individualisation based on personality. The total sample size is 60. Details have been presented as [Figure 1] in the flow chart of the study.
The patients registered in the outpatient department were allotted the number sequence generated by the software www.randomiser.com to opt for each group.
Statistical analysis was done using the Statistical Package for the Social Sciences version 20 (IBM India Ltd, Bangalore, Karnataka, India). The effectiveness of treatment with individualised Homoeopathy based on totality of symptoms and based on personality is evaluated using paired t-test. The test to compare the effectiveness of the intervention on Routine Assessment of Patient Index Data 3 (RAPID3) to a statistically significant level is done using independent t-test. All the tests were considered statistically significant at <0.05 level.
The Institutional Ethics Committee of School of Behavioural Sciences Mahatma Gandhi University, Kottayam, Kerala, had approved the study through the letter dated 22 September 2017. The Institution Ethics Committee of Dr. Padiar Memorial Homoeopathic Medical College also approved the study (IEC/DPMHMC/ECP-402/2019 dated 20 July 2019). Each patient was informed of the ethical issues related to the study through the informed consent form and was duly documented.
The study was performed following the protocol laid down in the 1964 Declaration of Helsinki.
The pre- and post-test scores of osteoarthritis patients were assessed with RAPID3 on the Multidimensional Health Assessment Questionnaire. RAPID3 measures physical function (FN), pain (PN) and patient global estimate (PTGE) and the three together as RAPID3. It is a standard tool in all rheumatic diseases and is usually correlated with the WOMAC scale for osteoarthritis.
Personality characters were framed according to 44-item inventory of John and Srivastava, known as Big-Five Inventory (BFI), the validated tool of trait theory of personality. In US and Canadian samples, the alpha reliability of BFI ranges from 0.75 to 90 averaging to above 80. It is most widely used to study the personality profiles of the patient suffering from various diseases including osteoarthritis. The 44-item BFI represents five dimensions in 44 questions. Each question has a keyword with a phrase that represents a trait with specificity in its meaning. Its measurement is on a five-point scale. It is translated into the regional language strictly adhering to the translation parameters of manual.
The third tool was a self-made tool to suit the purpose of this particular study. First, the keywords in every question of BFI were selected. A rubric in homoeopathic repertory exactly the same to the keyword in the inventory was identified and marked as the rubric for that trait word. The rubrics for this purpose were selected from the synthesis repertory 8.1 edited by Frederik Schroyens. If the same keyword was not present in the repertory, a rubric with similar meaning and content of the keyword in the question of inventory was set as the rubric for that trait word. In this manner, a list of 44 rubrics against 44 keywords in the inventory was prepared as the third tool for medicine selection based on personality. Here also, the translation manual of inventory was strictly adhered to. The reliability was calculated as the average percentile score and was found to be 92% which is highly significant.
First, the symptoms of the patient were recorded and the diagnosis was confirmed. The pre-test scores on FN, PN and PTGE were noted down subsequently in RAPID3 sheet. Patients selected for personality-based study were asked to mark their responses in the five-point scale of 44-item BFI.
The investigator had a postgraduate degree in Homoeopathy and had teaching experience of 20 years in the Department of Organon of Medicine in a homoeopathic medical college.
The investigator, after seeing the case records of patients, framed the totality of symptoms. This totality of symptoms was subjected to repertorisation to identify the suitable medicine. A careful search of the inventory of patients in the personality-based study arm revealed the most prominent personality characters. This was listed out first. The matching rubrics were identified against the most prominent characters of the patient from the tool already prepared. The selected rubrics were repertorised. In both the groups, the medicine was administered to the patient following the rules of potency and dose and repetition. Follow-up assessment was done every month. RAPID3 scores were evaluated at the 3rd month and 6th month. The baseline score and the final score after 6 months were used for analysis.
| Results|| |
[Table 1] and [Table 2] show a P value (P < 0.05) and t value at a significant level on the paired t-test. The findings presented in [Table 1] and [Table 2] show that there was a significant difference in the scores of FN, PN, global estimate and RAPID3 of patients suffering from osteoarthritis knee before and after treatment when an individualised homoeopathic medicine was administered based on totality of symptoms and based on personality.
|Table 1: Paired t-test value of medicine selection based on totality of symptoms|
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[Table 3] shows a P value and t value at a significant level. The result shows that there is a significant difference in the paired difference mean of RAPID3 score in patients suffering from osteoarthritis knee when an individualised homoeopathic medicine was administered based on totality of symptoms and based on personality.
|Table 3: Independent t-test to compare the effect of individualised Homoeopathy medicine administered based on totality of symptoms and personality on Routine Assessment of Patient Index Data 3 amongst patients suffering from osteoarthritis knee|
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The individualised medicine prescribed for osteoarthritis knee based on totality of symptoms were Sulphur and Kali. carb. (n = 4, 13.3%), Nat mur. and Lycopodium (n = 3, 10%), Ars alb. Graphites, Pulsatilla, Cal. Phos. Phosphorus and Rhus. tox (n = 2, 6.7%), Aur met. Kali bich. Lachesis and Cal. carb (n = 1, 3.3%). The medicines administered based on personality were Lachesis and Ars alb. (n = 5, 16.7%), Sulphur, Cal.carb, Phosphorus and Nat mur. (n = 3, 10%), Lycopodium and Pulsatilla (n = 2, 6.7%) and the rest of medicines were Nux vomica, Causticum, Ignatia and Aurum met. (n = 1, 3.3%). All the medicines were administered in 200th potency in two doses as night and morning dose. After the follow up of 3 months the same medicine in same potency were repeated as the first instance.
| Discussion|| |
The independent t-test values on paired difference mean show an inference that individualised medicine administered based on totality of symptoms was more effective than personality-based medicine in reducing the sufferings of osteoarthritis knee patients. Earlier studies on osteoarthritis proved the effectiveness of homoeopathic medicine administered based on individualised Homoeopathy. The individualised medicine selected in this study are more or less same to the referred study. Here, in this particular study, the remedies were selected focusing mainly on the constitutional nature that predisposes for osteoarthritis. The primary symptoms included were obesity, old age or menopausal age, over exertion of knee joint in cases based on their presence. To these primary symptoms, the general and particular characteristics of the patient with modalities were added to frame the totality. Therefore, this study squarely matches with the earlier findings that Homoeopathy is effective in reducing the sufferings of osteoarthritis patients when a medicine was administered based on individualised Homoeopathy. However, this particular study involving medicine selection based on the personality of BFI helped to move one step forwards to keep the view that homoeopathic medicine administration is effective when the medicine is selected based on personality characters also.
Individualised medicine is the rule in Homoeopathy. Various studies have been done using individualised homoeopathic medicine selection based either on the totality of characteristic symptoms as per Hahnemann or general symptoms as per Kent.,, There are research studies available on the role of personality in general and five-factor model of personality in particular in patients suffering from osteoarthritis. However, so far no works of literature available in peer-reviewed journals on valid attempts of linking personality with homoeopathic medicine selection. This study is an attempt for linking the trait theory of personality to homoeopathic medicine selection. Therefore, this study concentrates on the effectiveness as well as on the comparison of effectiveness of homoeopathic medicine administered based on totality of symptoms and administered based on personality in patients suffering from osteoarthritis.
The results indicate that medicine administration based on totality of symptoms is better in comparison to personality-based administration amongst patients suffering from osteoarthritis knee. Scrutiny of literature on the concept of sickness in Homoeopathy and nature of disease osteoarthritis will amply justify the results of this study. Homoeopathy is a therapeutic system developed by Hahnemann, who always insisted on the importance of totality of symptoms in framing the image of a patient. Hahnemann believed that the characteristic totality (aph. 153) framed from mental and emotional symptoms (aphs. 211 and 212), physical constitution and life situation (aph. 5) and particular symptoms will help to individualise the patient. He has shaped and sharpened the drug knowledge accordingly. That is why Kent said, 'The idea of sickness in man must be formed from the idea of sickness perceived in our materia medica. As we perceive the nature of sickness in a drug image, so must we perceive the nature of sickness in human being to be healed'.. Osteoarthritis is a degenerative disease related to the risk factors of ageing, heredity and psychosocial stress, which reflects that it is a disease having a constitutional affection and requires individualised treatment.
Small sample size was a limitation of this study. A major difficulty faced was the inclusion and conversion of the mental symptoms in the repertory to the contextual language of the BFI. A large number of symptoms and their medicine in the mind chapter of synthesis repertory are frequently and efficiently used for remedy selection in clinical practice other than that which comes under personality profiles, which has to be deliberately sacrificed when the prescription is restricted to individualisation based on any of the short inventory of modern personality psychology. Future studies are required with a larger sample size to confirm the findings and to find out the personality profiles that show a predilection to osteoarthritis. For that purpose, personality inventory having more trait words like NEO-Personality Inventory-Revised, which has 240 items, can be utilised.
The homoeopathic treatment based on the totality of symptoms is a person-centred, individualised treatment. Therefore, totality of symptoms-based individualisation is more effective in the treatment of disease showing affections due to risk factors that have an impact on the patient as a whole like osteoarthritis. The second reason is that Hahnemann has developed and nurtured Homoeopathy in such spirits that the patient's image and drug image are better matched only by individualised Homoeopathy based on totality of symptoms than any other parameters of individualisation. At the same time, the present study's results give a direction to the homoeopaths that homoeopathic medicine selection is feasible based on personality also. This study opens avenues for personality based studies in Homoeopathy.
| Conclusion|| |
This study shows that the administration of individualised homoeopathic medicine based on totality of symptoms is more effective as compared to individualised homoeopathic medicine merely based on personality amongst patients suffering from osteoarthritis knee.
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Conflicts of interest
| Annexure|| |
All the 44 items in the inventory carry the score 4. The transcribed words have the respective scores based on their availability in the homoeopathic repertory.
- Score 4 – Item in the inventory is present in the repertory in the same word/item in the inventory is present in the repertory in the same word with a given cross reference/item is represented in the repertory by a single synonym matched from a dictionary
- Score 3 – Most appropriate symptom present in the repertory similar in contextual meaning to the item in inventory/those symptoms present in the repertory in the same word to the item but presented as subrubrics
- Score 2 – Symptoms in the repertory that are similar in meaning to the items in inventory matched from a dictionary
- Score 1 – Symptoms in repertory that are the vague representation of items in inventory
- Score 0 – No matching symptoms present in the repertory to items in the inventory.
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