“Low back pain (LBP), discomfort, tension, or stiffness below the costal margin and above the inferior gluteal folds, is one of the most common conditions encountered in primary care, second only to the common cold”.1 Pain in the lower back area can relate to problems with the lumbar spine, the discs between the vertebrae, the ligaments around the spine and discs, the spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, or the skin covering the lumbar area. Kent’s repertory was used for these cases as being the most authentic repertory. A total number 36 patients of various ages, both sexes and various religions were included after having been clinically diagnosed as having low back pain by fulfilling inclusion and exclusion criteria. Follow up was done at a gap of 1 month for at-least 3 visits. The improvement of Low Back Pain was calculated by using the Roland-Morris Low Back Pain , a 24 point questionnaire (Appendix no. A) and general improvement as a whole of a patient was calculated by using a Quality of Life Scale, a 16 point Scale (Appendix no. B) according to the patient’s own realization of his quality of life and the Clinical Global Impression-severity scale (Appendix no. B) before and after treatment. It was used to assess the patient’s severity of clinical condition from the physician’s perspective. All data were calculated from the study of 33 of 36 subjects. Changes in the score of QOL and RMQ before and after treatment were analyzed using Z test. Changes in both scores were statistically significant (P < 0.05). There is statistically significant change in p value indicating homoeopathy was effective in the treatment of low back pain when remedies were selected using Kent’s Repertory (5% level of significance.)
KEYWORDS: Low back pain, Homoeopathic treatment, Kent’s Repertory, Hompath- Classic 8.0 software, RMQ, QOL, CGI.
- To show the clinical approach of KENT’S REPERTORY with its efficacy through the Holistic concept in the management of low backache.
- To get a clear conception about the backache predisposing factors, its pathogenesis clinical features, complications and the necessary investigations and also miasmatic concepts behind the disease and its pathology.
HYPOTHESIS: Homoeopathic treatment is efficacious for Low back pain selected on the basis of rubrics as stated in Kent’s Repertory.
METHODOLOGY: Cases of low back pain registered in the OPD & IPD of the National Institute of Homoeopathy were taken for the study. Patients of both sexes, of various age groups, from varied religions, willing to participate in the study of clinical work, of various socio-economic status should be included. Patients who were not willing to participate in the study, patients suffering from serious illness of other systems likely prolapsed of uterus, pelvic inflammatory disease, hypothyroidism, diabetes mellitus etc, and patients mentally retarded or taking any psychotropic drugs are kept in exclusion criteria. A prospective observational study was done at IPD & OPD of the National Institute of Homoeopathy. Proper case taking, repertorisation and reportorial analysis, and follow ups at regular intervals were the interventions which were taken. We uses a case recording format, Kent’s Repertory, the Computer software Hompath Classic, Roland-Morris Low Back Pain questionnaire: Quality of Life Scale [It is a 16 point Scale (Appendix no. A)] and CGI Scale format (Appendix no. B). These were taken as tools for this study throughout the period, about 12 months. After the completions of the study the results were be represented by appropriate statistical methods with proper analysis of the results.
OBSERVATIONS & RESULTS:
During the study the following observations were noted:
- Occurrence of low back pain in the age group of 41 – 50 years is found highest (52%) in this study. The lowest incidence is recorded in the age groups of 61 – 70 years (77%).
- The incidence of low back pain in males (61%) is found higher than females (39%), which also confirms the findings g In the Savills’ System of Clinical Medicine, that incidence is higher in males.
- In consideration of the religion, the study found that low back pain was higher in Islam (55%) than Hindu (45%).
- The socio-economic status shows higher incidence in middle class (58%) than the lower class (42%).
- Sulphur was found to be indicated in 6 cases (17%) out of the 33 cases that were prescribed medicine Rhus Tox in 5 cases and Bryonia in 4 cases were prescribed medicines which are coming next, covering 14% and 11% respectively. Natrum Sulph, Pulsatilla, Sepia, Thuja covered 6% and Calcarea Phos, Caust, Kali Bi, Lachesis, Medorrhinum, Mercurius 3%.
- From the point of improvement Rhus t, Pulsatilla, Sepia and Natrum Sulphuricum. were the most effective, showing marked improvement in almost all cases.
- In 33 cases treated with Homoeopathic medicines there were 22 cases of improvement showing 66.66% success, whereas 11 cases were not improve
- Regarding the miasmatic consideration of the case, Psora was found predominant in 67% of the, Sycosis in 21% and Syphilis in 12%. These proportions were mentioned by Hahnemann, who stated that if we deduct all chronic affections resulting from the unhealthy mode of living (§77) and also those that were produced by long and continued treatments of violent drugs (§74), then all the remainder results from the chronic miasms Syphilis, Sycosis and Psora, but chiefly and in infinitely the greater proportion is due to the Psoric mia (Vide §204).
Comparison of Clinical Global Impression-Severity Scale-before and after treatment:
|CGI(S) Scaling||No. of Patients|
|Before treatment||After treatment|
|1. Normal, not at all ill||–||4|
|2. Borderline ill||2||8|
|3. Mildly ill||5||9|
|4. Moderately ill||10||7|
|5. Markedly ill||11||4|
|6. Severely ill||5||1|
|7. Among the most extremely ill|
- At the time of entry the patient’s severity of disease was assessed using Clinical Global Impression –Severity Scale [1. Normal, not at all ill; 2. Borderline ill; 3. Mildly ill; 4. Moderately ill; 5. Markedly ill; 6. Severely ill; 7. Among the most extremely ill]. At the beginning of treatment 5 patients (Case No. 9, 13, 30, 3 & 7) were severely ill, 11 patients (Case No. 6, 31, 1, 8, 32, 2, 12, 23, 5, 21 & 29) were markedly ill, 10 patients (Case No. 11, 20, 27, 4, 14, 24, 18, 25, 26 & 17) were moderately ill, 5 patients (Case No. 28, 33, 16, 22 & 10) mildly ill and 2 patients (Case No. 19 & 15) were borderline ill. At the end of study CGI-S score was again assessed and it was found that there was significant reduction in severity of illness and maximum patients were under the category of mild illness followed by 8 patients (Case No. 14, 15, 27, 22, 24, 18, 1 & 19) under borderline illness and significantly 4 patients (Case No. 16, 20, 33 & 32) were under normal or not at all ill.
- The improvements were noted clinically in relation to pain by the “Roland-Morris Low Back Pain questionnaire” which is a 24 point Questionnaire. In this study observations were done over 33 patients. After assessment of the results of the RMQ scoring before and after treatment 22 patients were improved and 11 patients were not improved.
The improvements were noted clinically in relation to pain by the “Roland-Morris Low Back Pain questionnaire” which is a 24 point Questionnaire (Appendix no. A). At the beginning of treatment the mean score of RMQ of 33 patients was 15.12 ± 3.88 where as at the end of treatment was10.60 ± 4.58. The change in RMQ Scoring before & after treatment was analyzed by using Z Test. In 5% level of significance the critical value of Z (two tail test) 1.96. Since the calculated Z value (4.33) is higher than the above mentioned critical value (1.96). So, we conclude that the alternative hypothesis is true. The Quality of Life Scale is a 16 point Scale (Appendix no. B). Each point has 7 quality (Delighted 7, Pleased 6, Mostly Satisfied 5, Mixed 4, Mostly dissatisfied 3, Unhappy 2, Terrible 1) to take any one of them according to patient’s own realisation of his quality of life before and after treatment. Patient was asked to read each item and circle the number that best describes how satisfied subjects are at that time At the beginning of treatment the mean score of QOL of 33 patients was 50.30 ±17.41 where as at the end of treatment was 70.88 ± 19.13. The change in QOL Scale before & after treatment was analysed by using Z Test. In 5% level of significance the critical value of Z (two tail test) 1.96. Since the calculated Z value (4.569) is higher than the above mentioned critical value (1.96). So, we conclude that the alternative hypothesis is true. The study reflected the clinical approach of KENT’S Repertory in the management of low back pain following strict homoeopathic principles.
|Ash Purnendu 1||Concept and study design, data acquisition, data interpretation, revising manuscript.|
|Sharma Pawan 2||Data interpretation, revising manuscript.|
Authors read and approved the final manuscript.
The author would like to acknowledge Prof. Dr. S. K. Nanda, Director, National Institute of Homoeopathy for allowing us to carry out the study successfully in his institution and the author would also acknowledge Dr. Saroj Kumar Kayal, Reader Dept. of Homoeopathic Repertory, National Institute of Homoeopathy for guiding me to achieve success.
CONFLICT OF INTEREST STATEMENT:
The authors declare that they have no competing interest.
ROLE OF FUNDING SOURCES:
The authors received no external funding for the study. There was no institutional influence on the design, conduct and results reflected from the study.
The Roland-Morris Low Back Pain and Disability Questionnaire
Patient name: File Date:
Please read instructions: When your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today.
- I stay at home most of the time because of my back.
- I change position frequently to try to get my back comfortable.
- I walk more slowly than usual because of my back.
- Because of my back, I am not doing any jobs that I usually do around the house.
- Because of my back, I use a handrail to get upstairs.
- Because of my back, I lie down to rest more often.
- Because of my back, I have to hold on to something to get out of an easy chair.
- Because of my back, I try to get other people to do things for me.
- I get dressed more slowly than usual because of my back.
- I only stand up for short periods of time because of my back.
- Because of my back, I try not to bend or kneel down.
- I find it difficult to get out of a chair because of my back.
- My back is painful almost all of the time.
- I find it difficult to turn over in bed because of my back.
- My appetite is not very good because of my back.
- I have trouble putting on my sock (or stockings) because of the pain in my back.
- I can only walk short distances because of my back pain.
- I sleep less well because of my back.
- Because of my back pain, I get dressed with the help of someone else.
- I sit down for most of the day because of my back.
- I avoid heavy jobs around the house because of my back.
- Because of back pain, I am more irritable and bad tempered with people than usual.
- Because of my back, I go upstairs more slowly than usual.
- I stay in bed most of the time because of my back.
- The patient is instructed to put a mark next to each appropriate statement.
- The total number of marked statements are added by the clinician. Unlike the authors of the Oswestry Disability Questionnaire, Roland and Morris did not provide descriptions of the varying degrees of disability (e.g., 40%-60% is severe disability).
- Clinical improvement over time can be graded based on the analysis of serial questionnaire scores. If, for example, at the beginning of treatment, a patient’s score was 12 and, at the conclusion of treatment, her score was 2 (10 points of improvement), we would calculate an 83% (10/12 x 100) improvement.
SCALES FOR OUTCOME ASSESSMENT
- QUALITY OF LIFE SCALE (QOL)
Please read each item and circle the number that best describes how satisfied you are at this time. Please answer each item even if you do not currently participate in an activity or have a relationship. You can be satisfied or dissatisfied with not doing the activity or having the relationship.
|1.||Material comforts home, food, conveniences,
|2.||Health – being physically fit and vigorous||7||6||5||4||3||2||1|
|3.||Relationships with parents, siblings & other
relatives- communicating, visiting, helping
|4.||Having and rearing children||7||6||5||4||3||2||1|
|5.||Close relationships with spouse or
|7.||Helping and encouraging others,
volunteering, giving advice
|8.||Participating in organizations and
|9.||Learning- attending school, improving
understanding, getting additional knowledge
|10.||Understanding yourself – knowing your assets
and limitations – knowing what life is about
|11.||Work – job or in home||7||6||5||4||3||2||1|
|12.||Expressing yourself creatively||7||6||5||4||3||2||1|
|13.||Socializing – meeting other people,
doing things, parties, etc
|14.||Reading, listening to music, or observing
|15.||Participating in active recreation||7||6||5||4||3||2||1|
|16.||Independence, doing for yourself||7||6||5||4||3||2||1|
- CLINICAL GLOBAL IMPRESSION- Scale
- Clinical Global Impression –Improvement- Scale
Rate patient’s improvement on this seven point scale
1 – Patient very much improved
2 – Much improved
3 – Minimally improved
4 – Unchanged
5 – Minimally worse
6 – Much worse
7 – Very much worse
- Clinical Global Impression- severity- scale
Rate patient’s severity of illness on this seven point scale
1 – Normal, not at all ill
2 – Borderline ill
3 – Mildly ill
4 – Moderately ill
5 – Markedly ill
6 – Severely ill
7 – Among the most extremely ill
|SL. NO.||NAME||AGE/SEX||RELI||REG. NO.||DATE OF 1ST VISIT||MEDICINE||D M||OUTCOME MEASURES|
|4.||RM||38/M||H||69342||24/06/14||RHUS TOX||PSORA||NOT IMP|
|31.||JK||52/M||H||136944||05/09/14||NAT. MUR||SYCOSIS||NOT IMP|
- Charles W. Webb, Francis G. O’Connor: Low Back Pain in Primary Care: An Evidence-Based Approach. Current Diagnosis & Treatment in Family Medicine., 3e Chapter 24. The McGrawHill Companies Inc. 2011;257.
- Allen HC. Key Notes and characteristics with comparisons of the Leading Remedies of the Materia Medica. Reprint of 8th edition. New Delhi: B Jain publishers Pvt. Ltd.; 2004.
- Allen JH. The Chronic Miasms Psora and Pseudo-Psora. New Delhi: B Jain publishers Pvt. Ltd.; 2004.
- Bernoville F. Chronic Rheumatism. Reprint edition. New Delhi: B. Jain Publishers Pvt. Ltd.; 1998.
- Clarke JH. Rheumatism & Sciatica. 2nd revised & enlarged edition. London: James Epps & Co. Ltd; 1904.
- Kent JT. Repertory of Homoeopathic Materia Medica. New edition. Calcutta: Modern Homoeopathic Publication; 1995.