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The efficacy of homoeopathy in managing knee osteoarthritis: A comparative study with polarity analysis versus classical repertorisation using Boenninghausen’s therapeutic pocket book
*Corresponding author: Dr. Sana Parveen, Department of Homoeopathic Repertory and Case Taking, National Institute of Homeopathy, Kolkata, West Bengal, India. sana0193@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Parveen S, Behera L. The efficacy of homoeopathy in managing knee osteoarthritis: A comparative study with polarity analysis versus classical repertorisation using Boenninghausen’s therapeutic pocket book. J Integr Stand Homoeopath. doi: 10.25259/JISH_22_2025
Abstract
Objectives:
The primary objective of this study was to evaluate the comparative effectiveness of polarity analysis (PA) and classical repertorisation (CR) for managing knee OA. The secondary objectives were to evaluate the effectiveness of individualised homoeopathic medicine for treating OA and evaluate the utility of the CR method.
Material and Methods:
An open-label, randomised (1:1) trial was conducted at the National Institute of Homoeopathy, Kolkata, India. Patients were randomised to receive homoeopathic medicines repertorised with the PA (n = 35) or CR (n = 35) method using Boenninghausen’s therapeutic pocket book (BTPB). The Mann–Whitney test and Wilcoxon matched-pairs signed-rank test were used to compare the patients at baseline and after 6 months of treatment.
Results:
No statistically significant difference was seen between the two arms (PA and CR) after 6 months of treatment for the primary outcome. Within-group analysis done at baseline and after 6 months of treatment revealed that homoeopathic treatment and the CR method were effective. The frequently used medicines were Pulsatilla, Bryonia alba, Rhus tox, Sulphur, Calcarea carb, Arnica, Sepia, Phosphorus, Lycopodium, Natrum mur and Nux vomica.
Conclusion:
Prescriptions made using Heiner Frei’s PA do not produce any effect different from prescriptions made through the CR method using the BTPB in patients with knee OA. The homoeopathic treatment and prescription done through CR were found to be effective in managing knee OA. Further trials of similar design and enhanced methodological rigour are warranted.
Keywords
Boenninghausen’s therapeutic pocket book
Classical repertorisation
Homoeopathy
Osteoarthritis knee
Polarity analysis
INTRODUCTION
Osteoarthritis (OA) is the most common form of arthritis; it affects 3.3–3.6% of the population globally. It causes moderate-to-severe disability in 43 million people, making it the 11th most debilitating disease worldwide.[1] Anti-inflammatory medications are the most commonly used treatments. However, they are only helpful for relieving OA symptoms and are sometimes associated with adverse effects. Surgery is only considered for those who exhibit severe symptoms and are unresponsive to conservative therapy.[2] At present, knee arthroplasty is the most effective treatment for advanced OA; however, the cost of surgery is substantial. Therefore, the focus has shifted to the prevention and delaying the progression of disease at an early stage.[3] Recent studies have shown the effectiveness of homoeopathy over allopathic medicines in treating OA, with efficacy equivalent to that of acetaminophen.[3-5] Homoeopathic gel was also found to be as effective as an anti-inflammatory gel.[6] Several studies provide evidence supporting the effectiveness of homoeopathy in treating knee OA.[7-11]
Boenninghausen’s Therapeutic Pocket Book (BTPB), published in 1846, is chiefly used for classical repertorisation (CR). At the time of its publication, it was seen as a revolutionary approach compared to existing processes. Boenninghausen constructed this repertory using the principle of analogy. It is useful when there is a paucity of symptoms, where there is no presence of marked mental, rare or strange symptoms; where modalities predominate; where particulars and concomitants are marked and where there are more pathological or objective symptoms. Unfortunately, a lack of proper additions and revisions has limited its usefulness.[12]
In 2005, Heiner Frei devised a new approach toward repertorisation based on the BTPB. Polarity analysis (PA) is a precisely defined method of repertorisation and homoeopathic prescription which achieves great reliability (probability of cure) in the cure of illnesses and complaints. It is the development of Boenninghausen’s concept of contraindications and based on the grade scale used in the BTPB. The contradiction may refer to polar symptoms, i.e. symptoms that include the opposite (e.g. thirst vs. thirstlessness; < cold vs. > cold; desire for fresh air vs. aversion to fresh air).[13] PA has also been found to improve the results in comparison with conventional homoeopathic treatment.[14] CR continues to dominate homoeopathic practice due to its historical roots and widespread teaching; PA remains a relatively underutilised methodology. However, its structured, quantitative approach to symptom analysis offers a potential alternative that warrants systematic evaluation. By undertaking a comparative study of these two methods, this study aims to explore whether PA offers clinical value that could complement or enhance CR, particularly in terms of objectivity, time efficiency and remedy precision.
However, to the best of our knowledge, none of the existing research has focused on the repertorial approach when selecting the similimum.[7-11] Therefore, we performed a comparative analysis between two repertorisation methods: PA and CR when managing patients with knee OA.
Objectives
Primary objective
To compare the effectiveness of PA and CR in the management of knee OA.
Secondary objective
To evaluate the effectiveness of individualised homoeopathic medicine in the treatment of knee OA
To evaluate the utility of the CR method.
Hypothesis
Null hypothesis (H0)
Homoeopathic prescriptions made using Frei’s PA cannot produce any effect different from prescriptions made through the CR method using the BTPB in the management of knee OA, i.e. reduction in the mean knee injury and OA outcome score (KOOS) in the PA group = reduction in the mean KOOS in the CR group.
Alternative hypothesis (HA)
Homoeopathic prescriptions made using Frei’s PA can produce significantly different effects from prescriptions through CR using the BTPB in the management of knee osteoarthritis (OA), i.e. reduction in the mean KOOS in the PA group = reduction in the mean KOOS in the CR group.
MATERIAL AND METHODS
Study design
This is an open-label, randomised (1:1) two-parallel-arm clinical study. The trial protocol and full dissertation were submitted as a postgraduate thesis by the primary author to the West Bengal University of Health Sciences, Kolkata, India.
Participants
Patients with knee OA aged 40–75 years attending outpatient and inpatient departments of the National Institute of Homoeopathy, Kolkata, India, from March 2021 to December 2021 were selected. The patients were diagnosed with knee OA according to the clinical diagnosis/clinical and radiographic diagnosis of the American College of Rheumatology classification criteria. Cases suitable for repertorisation in the BTPB with complete symptoms, where generals were lacking, with prominent concomitants, paucity of symptoms with scattered modality and no characteristics were selected. While comorbidities were considered, patients were included if they were on conventional drug therapies (e.g. antidiabetics, antihypertensives, thyroid drugs) and the conditions were under control. Finally, those willing to take part in the study and provide written consent were also included.
The exclusion criteria were (1) patients with knee pain caused by inflammatory, malignant or autoimmune disease or other reasons such as serious valgus-defective or varus-defective position, (2) patients who had undergone knee surgery such as arthroscopy of the affected knee in the past year, (3) patients who had received chondroprotective or intra-articular injections in the past 4 months, (4) patients who had received systemic corticoid treatment or beginning of a new treatment for OA in the past 4 weeks and (5) patients currently receiving homoeopathic treatment for chronic condition(s).
Intervention
Patients were randomized into one of the two trial arms in a 1:1 ratio on the basis of odd or even, according to the sequential order of their enrolment. Those with an odd enrolment number (PA) received the homoeopathic prescription as per PA and those with an even enrolment number (CR) received the prescription as per the CR method. Homoeopathic medicines in centesimal/50 millesimal potency, dosage and repetition were prescribed depending on each patient’s individual requirement. When medicines in the centesimal potency were prescribed, each dose consisted of 4–6 globules (No. 30) medicated with a single drop of the indicated homoeopathic dilution; the globules were taken orally on a clean tongue, with the patient on an empty stomach. When the LM potency was used, treatment was initiated with 0/1 potency, followed by the next higher potency, serially as per the need of the case. Medicines were obtained from the college pharmacy, which was procured from a GMP-certified firm (SBL Pvt Ltd., New Delhi, Delhi, India). On subsequent visits, the medicines were repeated in compliance with homoeopathic principles. Along with medicines, both arms received advice on general management, i.e. physiotherapy and reduction of adverse mechanical factors (weight loss if obese, use of shock-absorbing footwear and use of a walking stick for painful knees).
Study procedure
The study was conducted on the patients from March 2021 to December 2021, after obtaining approval from the hospital’s Institutional Ethical Committee. A random selection of 84 cases of knee OA was screened for the study, and 70 were finally included. A detailed case-taking of each participant was carried out, the symptoms were evaluated and the totality of symptoms was framed in accordance with the directions laid down by Dr. Hahnemann in the Organon of Medicine.[15] The homoeopathic medicine was selected based on the instructions in the Organon of Medicine, after using PA software, Hompath firefly mobile application (Mind Technologies Pvt Ltd; Version: 5.0.0, Mumbai, Maharashtra, India) and referring to Allen’s Keynotes and Boericke’s new manual of Homoeopathic Materia Medica, as and when required.[16-18] Each patient was followed up regularly for 6 months.
Outcome assessment
The response and improvement of the patients were observed in terms of the primary outcome.
Primary outcome
The primary outcome was the KOOS.[19] The KOOS was assessed using a questionnaire at baseline and 6 months. The KOOS consists of five subscales: Pain (nine items), other symptoms (seven items), function in activity of daily living (17 items), function in sport and recreation (Sport/Rec) (five items) and knee-related quality of life (QoL) (four items). The previous week was the time period considered when answering the questions. Standardised answer options are given 5 Likert boxes and each question is assigned a score from 0 to 4. Pre-designed Excel spreadsheets with formulae were used to calculate the five subscale scores.
Sample size
We planned to achieve a target sample of 70 patients (35 in each group) within the stipulated time (α = 0.05 and power 80%). Considering a maximum of 20% dropouts, the total sample size was computed to be 84. A formal sample size calculation could not be done.
Statistical techniques and data analysis
The study followed the intention-to-treat approach; i.e. every included patient was entered into the final analyses. Missing values were replaced using the last observation carried forward. Baseline descriptive data (categorical and continuous) were presented in terms of absolute values, percentages, mean, standard deviations and confidence intervals, as appropriate. Parametric or non-parametric tests were used as inferential statistics as per normality or non-normality of data distribution, respectively. Group differences (independent observations) were tested at baseline (to check comparability) and after 6 months using statistical tests as appropriate. Dependent observations of continuous outcomes at baseline and at 6 months from baseline were also compared using appropriate tests. A p < 0.01 two-tailed test was considered statistically significant.
RESULTS
As per the pre-specified inclusion criteria, 84 patients were screened; 14 were screened out based on the exclusion criteria. Baseline socio-demographic and outcome data were obtained for these 70 enrolled patients and they underwent individualised homoeopathic treatment. After 6 months of intervention, outcome data were recorded again. During the course of treatment, 17 dropped out (09 in PA and 08 in CR); 53 completed the trial [Figure 1].
Baseline descriptive statistics
The demographics of the patients are provided in Table 1. After applying the unpaired t-test in age distribution, body mass index and KOOS and the Chi-square test in the gender distribution, residence, food habits, marital status, educational status, employment and income status of both groups PA and CR, no significant difference was found between both groups. This implies a comparable distribution of subjects in the PA and CR groups.
| Features | PA (n=35) | CR (n=35) | p-value |
|---|---|---|---|
| Age (years)a | 52.83±9.07 | 53.66±8.78 | 0.69 |
| Genderb | 0.60 | ||
| Female | 26 (74.28%) | 23 (65.71%) | |
| Male | 9 (25.71%) | 12 (34.28%) | |
| Residenceb | 0.71 | ||
| Urban | 20 (57.14%) | 23 (65.71%) | |
| Semi-urban | 11 (31.42%) | 8 (22.85%) | |
| Rural | 4 (11.42%) | 4 (11.42%) | |
| BMIa | 26.34±5.02 | 25.89±4.75 | 0.70 |
| Food habitb | 0.59 | ||
| Vegetarian | 11 (31.42%) | 8 (22.85%) | |
| Non-Vegetarian | 24 (68.57%) | 27 (77.14%) | |
| Marital statusb | >0.999 | ||
| Married | 0 | 0 | |
| Unmarried | 31 (88.57%) | 31 (88.57%) | |
| Other | 4 (11.42%) | 4 (11.42%) | |
| Educational statusb | 0.33 | ||
| Upto Class 10 | 22 (62.85%) | 27 (77.14%) | |
| Upto Class 12 | 10 (28.57%) | 5 (14.28%) | |
| Graduate and higher | 3 (8.57%) | 3 (8.57%) | |
| Employmentb | 0.96 | ||
| Unemployed | 21 (60%) | 19 (54.28%) | |
| Employed | 4 (11.42%) | 4 (11.42%) | |
| Retired | 0 | 0 | |
| Business | 5 (14.28%) | 6 (17.14%) | |
| Others | 5 (14.28%) | 6 (17.14%) | |
| Income statusb | 0.45 | ||
| <Rs10,000/month | 22 (62.85%) | 26 (74.28%) | |
| Rs10,000-Rs20,000/month | 10 (28.57%) | 8 (22.85%) | |
| >Rs20,000/month | 3 (8.57%) | 1 (2.85%) | |
| KOOSa | |||
| Pain | 34.17±15.23 | 29.34±15.80 | 0.19 |
| Symptoms | 33.26±20.15 | 26.74±15.89 | 0.13 |
| ADL | 43.00±16.65 | 34.74±18.49 | 0.05 |
| Sports and rec | 21.43±19.85 | 18.51±15.26 | 0.49 |
| QoL | 30.40±9.88 | 29.43±9.10 | 0.67 |
aContinuous data presented as mean±standard deviations and unpaired t-tests applied; bCategorical data presented as absolute values (percentages) and chi- squared test or Fisher’s exact test applied; p value less than 0.05 two-tailed was considered as statistically significant. PA: Polarity analysis , CR: Classical repertorisation, KOOS: Knee injury and osteoarthritis outcome score, BMI: Body mass index, ADL: Activity of daily living, QoL: Quality of living.
Group PA showed mild improvement in pain (40%), symptoms (31.42%) and QoL (31.42%) while group CR showed moderate (31.42%) improvement in symptoms and mild improvement in pain (31.42%) and QoL (48.85%).
The test statistics were calculated using GraphPad Prism, Boston, Massachusetts, USA (version 8.0.0). Data for most of the domains of KOOS did not fall under the normal distribution when the Shapiro–Wilk test was applied. The Mann–Whitney test was applied to compare both groups. There was no statistically significant difference between the two groups in all five domains of KOOS; p < 0.01 was considered statistically significant [Table 2].
| KOOS | |||||
|---|---|---|---|---|---|
| KOOS subscales change from baseline | Groups | Median | Inter-quartile range | Mann-Whitney U | p-value |
| Pain | Group PA | 12 | 16 | 577.5 | 0.68 |
| Group CR | 11 | 16 | |||
| Symptoms | Group PA | 15 | 21 | 523.5 | 0.29 |
| Group CR | 18 | 18 | |||
| ADL | Group PA | 3 | 9 | 473 | 0.09 |
| Group CR | 7 | 12 | |||
| Sport/rec | Group PA | 0 | 5 | 505.5 | 0.17 |
| Group CR | 5 | 5 | |||
| QoL | Group PA | 7 | 13 | 574.5 | 0.65 |
| Group CR | 12 | 18 | |||
The threshold value for p is < 0.01 ADL: Activity of daily living, QoL: Quality of life, PA: Polarity analysis, CR: Classical repertorisation, KOOS: Knee injury and osteoarthritis outcome score.
The Wilcoxon matched-pairs signed-rank test was applied for comparison between baseline and 6-month treatment in both groups, specifically in Group CR. Statistically significant differences were seen in all five domains of KOOS between baseline and after 6 months of therapy in the CR group (p < 0.01). This helped us conclude that the homoeopathic treatments and the prescriptions done through CR were effective [Tables 3 and 4].
| KOOS | |||||
|---|---|---|---|---|---|
| KOOS subscales | Groups | Median | Inter-quartile range | Sum of signed ranks (W) | p-value |
| Pain | Baseline | 31 | 23 | 1426 | <0.0001**** |
| 6 months | 44 | 20.75 | |||
| Symptoms | Baseline | 25 | 25 | 1431 | <0.0001**** |
| 6 months | 46 | 21 | |||
| ADL | Baseline | 34.50 | 23.5 | 1225 | <0.0001**** |
| 6 months | 43.50 | 21.25 | |||
| Sport/rec | Baseline | 15 | 19 | 467.0 | <0.0001**** |
| 6 months | 20 | 10 | |||
| QoL | Baseline | 31 | 13 | 1145 | <0.0001**** |
| 6 months | 38 | 13 | |||
****means extremely significant, KOOS: Knee injury and osteoarthritis outcome score.
| KOOS | |||||
|---|---|---|---|---|---|
| KOOS subscales | Groups | Median | Inter-quartile range | Sum of signed ranks (W) | p-value |
| Pain | Baseline | 28 | 25 | 378 | <0.0001**** |
| 6 months | 44 | 20 | |||
| Symptoms | Baseline | 21 | 18 | 378 | <0.0001**** |
| 6 months | 46 | 22 | |||
| ADL | Baseline | 31 | 21 | 325 | <0.0001**** |
| 6 months | 41 | 18 | |||
| Sport/rec | Baseline | 15 | 19 | 178 | <0.0001**** |
| 6 months | 20 | 10 | |||
| QoL | Baseline | 25 | 13 | 299 | <0.0001**** |
| 6 months | 38 | 13 | |||
****means extremely significant, KOOS: Knee injury and osteoarthritis outcome score.
Medicines indicated at baseline
The most common remedies indicated and prescribed were (in order from most frequently to least frequently prescribed) Pulsatilla, Bryonia alba, Rhus tox, Sulphur, Calcarea carb, Arnica, Sepia, Phosphorus, Lycopodium, Natrum mur and Nux vomica [Table 5].
| Medicines | Total | Group PA | Group CR |
|---|---|---|---|
| Aloe socotrina | 1 | 0 | 1 |
| Arnica montana | 4 | 3 | 1 |
| Bryonia alba | 9 | 6 | 3 |
| Calcarea carb | 5 | 4 | 1 |
| Causticum | 2 | 1 | 1 |
| Graphites | 1 | 0 | 1 |
| Ignatia | 1 | 0 | 1 |
| Lachesis | 1 | 0 | 1 |
| Lycopodium | 3 | 0 | 3 |
| Natrium carb | 1 | 1 | 0 |
| Natrium mur | 3 | 2 | 1 |
| Natrium phos | 1 | 0 | 1 |
| Natrium sulph | 1 | 1 | 0 |
| Nux Vomica | 3 | 3 | 0 |
| Phosphorus | 4 | 1 | 3 |
| Pulsatilla | 11 | 4 | 7 |
| Rhus tox | 8 | 3 | 5 |
| Sepia | 4 | 1 | 3 |
| Sulphur | 7 | 5 | 2 |
PA: Polarity analysis, CR: Classical repertorisation
DISCUSSION
To the best of our knowledge, this is the first trial that provides a comparative approach in terms of prescriptions made through different repertorisation methods (PA and CR) in the management of knee OA. This randomised, open-label clinical trial found that after 6 months of intervention, there was no statistically significant difference between PA and CR in terms of the primary outcome. Despite this, the CR group exhibited clinically meaningful improvement in pain and function, demonstrating that its effectiveness in knee OA management was similar to several prior studies.[7-11] In contrast, another study (a 2-week pilot feasibility trial in West Bengal) found that homoeopathy did not appear to be superior to placebo.[20] The discrepancy likely arises from methodological differences, sample sizes and duration of follow-up.
Strengths of the study
No placebo control was used; hence, ethically, the study was less vulnerable. The treatment was administered, adhering to the principles of homoeopathy with two different approaches of repertorisation based on individualisation.
Weaknesses of the study
The sample size was small and was based on an assumption. The trial was open; no blinding was used. Thus, patient selection bias, treatment assignment bias, patient evaluation bias and data analysis bias might have affected the study outcomes. The follow-up duration was 6 months, which might be considered insufficient in a disease like OA. The loss to follow-up was more than 10% due to the unprecedented situation of COVID-19.
Unanswered questions and future research
Simultaneous advice on physiotherapy measures could have overestimated the effect size. Therefore, whether the effect size is affected because of physiotherapy cannot be answered by this study. A comparative study between physiotherapy and individualised homoeopathic medicines is required to establish better the effectiveness of individualised homoeopathic medicines. Moreover, the use of different potency scales (LM and centesimal) was not standardised across cases, which may have introduced variability in treatment outcomes; however, this reflects routine clinical practice and was not the focus of the present study. Future studies could be designed to specifically evaluate the comparative effectiveness of different potency scales in the treatment of OA. Trials need to be conducted with enhanced methodological rigour.
CONCLUSION
A prospective, open-label, randomized, clinical trial with two parallel arms was conducted on 70 patients with knee OA, with 35 patients each in the PA and CR groups. There was no statistically significant difference between the two arms after 6 months of intervention for the primary outcome (p < 0.01). Homoeopathic treatment and prescription conducted using CR was found to be effective in managing knee OA. Further trials of similar design and enhanced methodological rigour are warranted. However, this study provides a direction and feasibility indication for further effectiveness trials with greater methodological rigour.
Acknowledgements:
The authors acknowledge Dr Subhas Singh, Director, National Institute of Homoeopathy, for allowing us to carry out the study successfully in this institution. The authors are also grateful to the patients for their participation in the study.
Ethical approval:
The research/study was approved by the Institutional Review Board at National Institute of Homoeopathy, number 5-23/NIH/PG/Ethical Comm.2009/Vol.VII/158, dated 07 October 2020. CTR Number: CTRI/2021/03/031951.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understand that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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