The efficacy of the homoeopathic similimum in the ...
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The Efficacy of the Homoeopathic Similimum in the Treatment of Irritable Bowel Syndrome in Women By GERALDINE CHANTAL HACHLER A dissertation submitted as partial fulfilment for the MASTERS DEGREE IN TECHNOLOGY in Homoeopathy in the Faculty of Health Sciences at the University of Johannesburg Supervisor: Dr. Kathryn Peck 2008
Transcript of The efficacy of the homoeopathic similimum in the ...
The Efficacy of the Homoeopathic Similimum in the Treatment of Irritable Bowel Syndrome in Women
By
GERALDINE CHANTAL HACHLER
A dissertation submitted as partial fulfilment for the
MASTERS DEGREE IN TECHNOLOGY
in
Homoeopathy
in the
Faculty of Health Sciences
at the
University of Johannesburg
Supervisor: Dr. Kathryn Peck
2008
DECLARATION
I, Geraldine Hachler, declare that this dissertation is my own unaided work. It is being
submitted for the Degree of Master of Technology at the University of Johannesburg. It has
not been submitted before for any degree or examination in any other Technikon or University.
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ACKNOWLEDGEMENTS
I am deeply grateful to Dr. Kathryn Peck, whose dedication and guidance was invaluable.
Thank you for all your time, effort, and enthusiasm.
Thank you to Dr. Jaci Schultz for her valuable time and input.
Thank you to Anneli at Statkon for all her effort in analysing the study results.
Thank you to all the women who took part in this study.
Thank you to my family for providing me with endless support and encouragement.
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DEDICATION
This study is dedicated to my family and Brendan, without whose love, encouragement and
support I could not have achieved all that I have.
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ABSTRACT
Irritable bowel syndrome (IBS) is a multifactoral disorder of the gastrointestinal tract causing
disturbances in gastric motility, resulting in abdominal pain, bloating and abnormal bowel
movements. It is defined as a 'disorder of gut function in the absence of structural pathology'
(Palmer et a!, 2002). It is the most commonly encountered functional gastrointestinal disorder
in the primary and secondary health care system with a prevalence in the general population of
five to twenty percent (Bellini et a!, 2005). No definite aetiological factor has been isolated,
but factors such as psychological stress, anxiety and depression, certain dietary intolerances,
increase in abnormal sensitivity to visceral distension, and hormonal changes in women have
been implicated in compounding the symptoms of IBS (Ohman & Simren, 2007). Current
treatment regimes include dietary changes and symptomatic relief using allopathic
medications, which come with the risk of side-effects and may lead to dependency (University
of Maryland Medical Center, 2007). Homoeopathic studies which have addressed the physical
symptoms as well as the psychological contributing factors associated with IBS, have recorded
favourable results when treating this syndrome (Mathie & Robinson, 2006) .
The aim of this research was to determine the efficacy of Homoeopathic Similimum treatment
in IBS.
In order to recruit volunteers, this study was advertised in local newspapers, pharmacies and at
the University of Johannesburg's Doornfontein Campus. Volunteers completed the Rome III
Criteria evaluation to determine their suitability for this study, with the likelihood of any other
bowel pathology having been excluded. Ten suitable female volunteers, ranging in age from
twenty to thirty five, were selected having met the inclusion criteria. Over a period of three
months, each participant partook in four homoeopathic consultations. The initial consultation
involved the completion of the information and consent form, an explanation of the research
procedures, general well-being and general symptom rating questionnaires were completed, a
full homoeopathic case history was taken, and a physical examination was performed. A
baseline of four weeks without treatment followed. Participants were requested to complete
daily symptom rating scales and keep a daily food diary in the four weeks between
consultations. This was continued throughout the study period. The subsequent follow-ups, of
which there were three, consisted of a follow-up on the initial consultation, completion of
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general well-being and symptom rating questionnaire, and a physical examination. A
homoeopathic similimum remedy was chosen based on each participant's unique symptoms.
Using physical, mental, and emotional symptoms in accordance with classical homoeopathic
principles, a single remedy that most suited the individual was chosen and prescribed. It was
predicted that the study would provide an alternative and safe treatment option to relieve the
symptoms ofiBS.
The results of the study showed that the homoeopathic similimum remedy does not provide a
statistically significant improvement in the symptoms of IBS. Clinically, however, most
participants experienced a general trend of improvement in physical symptoms and general
well-being .
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TABLE OF CONTENTS
DECLARATION .................................................................................................................... i
ACKNOWLEDGEMENTS ................................................................................................... ii
DEDICATION ........................................................................................................................ iii
ABSTRACT ............................................................................................................................ iv
TABLE OF CONTENTS ....................................................................................................... vi
LIST OF APPENDICES ....................................................................................................... x
LIST OF FIGURES ............................................................................................................... x
LIST OF TABLES ................................................................................................................. xi
CHAPTER ONE -1. REVIEW OF RELATED LITERA TURE ....................................................................... l
- 1.1 Problem Statement ........................................................................................................... I -- 1.2 Irritable Bowel Syndrome ............................................................................................... 3
- 1.2.1 Symptoms ........................................................................................................................ 3
1.2.2 Aetiology ......................................................................................................................... 4
1.2.3 Diagnosis ......................................................................................................................... 11
1.3 Current Treatment Options for IBS .............................................................................. 13
1.3 .1 Dietary Management. ...................................................................................................... 13
1.3 .2 Pharmacology Treatment of IBS ..................................................................................... 14
1.3 .3 Herbal Medicine .............................................................................................................. 16
1.3 .4 Psychological Therapeutic Approach for IBS ................................................................ 16
1.3.5 Homoeopathic Treatment. ............................................................................................... l7
- 1.4 Homoeopathy: A Review ................................................................................................. 17
- 1.4.1 Fundamental Principles of Homoeopathy ....................................................................... 17
- 1.4.2 Homoeopathic Remedies ................................................................................................ 20
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1.4.3 Case Taking ..................................................................................................................... 22
1.4.4 Case Management ........................................................................................................... 23
1.4.5 Homoeopathy and IBS .................................................................................................... 24
CHAPTER TWO
2. METHODOLOGY AND MATERIALS .......................................................................... 25
2.1 Sample and Study Design .................................................................................................. 25
2.2 Recruitment of Participants ................................................................................................ 25
2.3 Research Procedures .......................................................................................................... 26
2.4 Administration ofRemedies .............................................................................................. 27
2.5 Tools Utilised ..................................................................................................................... 27
- 2.5.1 Gastrointestinal Symptom Rating Questionnaire ............................................................ 27
- 2.5.2 General Well-Being Questionnaire ................................................................................. 28
- 2.5.3 Daily Food Diary ............................................................................................................ 29
2.5.4 Daily Symptom Grading Sheet ....................................................................................... 29
- 2.5.5 Friedman Test. ................................................................................................................. 29 -- CHAPTER THREE
3. CASE STUDIES ................................................................................................................. 30
3.1 CASE ONE ....................................................................................................................... 30
3.1.1 First Consultation-August 2007 ..................................................................................... 30
3 .1.2 Second Consultation-September 2007 ............................................................................ 31
- 3 .1.3 Third Consultation-October 2007 ................................................................................... 31
- 3.1.4 Fourth Consultation-November 2007 ............................................................................. 32
3 .1. 5 Overview and Discussion of Case One ........................................................................... 34 -3.2 CASE TWO ...................................................................................................................... 35 - 3.2.1 First Consultation-August 2007 ...................................................................................... 35
- 3 .2.2 Second Consultation-September 2007 ............................................................................ 36 - 3 .2.3 Third Consultation-October 2007 ................................................................................... 3 7 - 3.2.4 Fourth Consultation-November 2007 ............................................................................. 37 - 3.2.5 Overview and Discussion of Case Two .......................................................................... 39 -Vll
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3.3 CASE THREE .................................................................................................................. 40
3.3.1 First Consultation-August 2007 .................................................................................... .40
3.3.2 Second Consultation-September 2007 ........................................................................... .41
3.3.3 Third Consultation-October 2007 .................................................................................. .41
3.3.4 Fourth Consultation-November 2007 ............................................................................. 42
3.1.5 Overview and Discussion of Case Three ....................................................................... .44
3.4 CASE FOUR ..................................................................................................................... 45
3.4.1 First Consultation-September 2007 ............................................................................... 45
3.4.2 Second Consultation-October 2007 ................................................................................ 46
3.4.3 Third Consultation-November 2007 .............................................................................. .46 -- 3.4.4 Fourth Consultation-December 2007 .............................................................................. 47
3.4.5 Overview and Discussion of Case Four ......................................................................... .49
-3.5 CASE FIVE ...................................................................................................................... 50
3.5.1 First Consultation-October 2007 .................................................................................... 50
- 3.5.2 Second Consultation-November 2007 ............................................................................ 51
3.5.3 Third Consultation-December 2007 ................................................................................ 51
- 3.5.4 Fourth Consultation-January 2008 ......................... , ........................................................ 52 - 3.5.5 Overview and Discussion of Case Five ..... , .................................................................... 54
3.6 CASE SIX ................................................................................................................... , ..... 55
3.6.1 First Consultation-October 2007 .. , ................................................................................. 55
3.6.2 Second Consultation-November 2007 ........... , ................................................................ 56
3.6.3 Third Consultation-December 2007 ..... , .......................................................................... 56
3.6.4 Fourth Consultation-January 2008 ....... , .......................................................................... 57 , ... 3 .6.5 Overview and Discussion of Case Six ............................................................................ 59
- 3.7 CASE SEVEN ................................................................................................................... 60 - 3.7.1 First Consultation-October 2007 .................................................................................... 60 - 3.7.2 Second Consultation-November 2007 ............................................................................ 61 - 3.7.3 Third Consultation-December 2007 ................................................................................ 61 - 3. 7.4 Fourth Consultation-January 2008 .................................................................................. 62 - 3.7.5 Overview and Discussion of Case Seven ........................................................................ 64
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3.8 CASE EIGHT ................................................................................................................... 65
3 .8.1 First Consultation-December 2007 ................................................................................ 65
3.8.2 Second Consultation-January 2008 ................................................................................. 66
3.8.3 Third Consultation-February 2008 .................................................................................. 66
3.8.4 Fourth Consultation-March 2008 .................................................................................... 67
3.8.5 Overview and Discussion of Case Eight ......................................................................... 69
3.9 CASE NINE ...................................................................................................................... 70
3.9.1 First Consultation-December 2007 ................................................................................ 70
3.9.2 Second Consultation-January 2008 ................................................................................. 71
3.9.3 Third Consultation-February 2008 .. , ............................................................................... 71
... 3.9.4 Fourth Consultation-March 2008 .................................................................................... 72
- 3.9.5 Overview and Discussion of Case Nine .......................................................................... 74
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- 3.10 CASE TEN ...................................................................................................................... 75
3.10.1 First Consultation-February 2008 ................................................................................ 75
- 3.10.2 Second Consultation-March 2008 ................................................................................. 76
• 3.1 0.3 Third Consultation-April 2008 ...................................................................................... 76
- 3.1 0.4 Fourth Consultation-May 2008 ..................................................................................... 77 - 3.1 0.5 Overview and Discussion of Case Six .......................................................................... 79
- CHAPTER FOUR
4. RESULTS ........................................................................................................................... 80
4.1 Introduction ........................................................................................................................ 80
- 4.2 Statistics ............................................................................................................................. 81
4.3 Friedman Test Result ......................................................................................................... 82
4.3. 1 Bloating ........................................................................................................................... 82
4.3.2 Abdominal Pain ............................................................................................................... 83 - 4.3.3 Flatulence ........................................................................................................................ 84
4.3.4 Diarrhoea ......................................................................................................................... 85
4.3.5 Constipation .................................................................................................................... 86 - 4.3.6 Conclusion ofFriedman Test .......................................................................................... 87 --- IX
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5. DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS ................................ 88
5.1 Discussion and Conclusion ................................................................................................ 88
5.2 Recommendations .............................................................................................................. 89
5.2.1 Further Research ............................................................................................................. 89
5.2.2 Benefits and Limitations ofthe Study ............................................................................. 89
REFERENCES ....................................................................................................................... 90
LIST OF APPENDICES
Appendix A: Rome III Criteria for IBS ................................................................................... 98
Appendix B: Information and Consent Form .......................................................................... 99
- Appendix C: Homoeopathic Interview Form and Physical Examination ................................ l01
Appendix D: Gastrointestinal Symptom Rating Questionnaire ............................................... 106
- Appendix E: General Well-being Questionnaire ..................................................................... ! 07
- Appendix F: Daily Food Diary ................................................................................................ 109
• Appendix G: Daily Symptom Grading Sheet.. ......................................................................... l10
-- LIST OF FIGURES
Figure 3-1: Gastrointestinal Symptom Rating Questionnaire for Participant One .................. 33
Figure 3-2: General Well-Being Questionnaire for Participant One ....................................... 33
Figure 3-3: Sum of Physical and General Well-Being for Participant One ............................. 34
Figure 3-4: Gastrointestinal Symptom Rating Questionnaire for Participant Two .................. 38
Figure 3-5: General Well-Being Questionnaire for Participant Two ....................................... 38
Figure 3-6: Sum of Physical and General Well-Being for Participant Two ............................ 39
Figure 3-7: Gastrointestinal Symptom Rating Questionnaire for Participant Three ............... .43 - Figure 3-8: General Well-Being Questionnaire for Participant Three .................................... .43
·- Figure 3-9: Sum of Physical and General Well-Being for Participant Three ......................... .44
Figure 3-10: Gastrointestinal Symptom Rating Questionnaire for Participant Four .............. .48 - Figure 3-11: General Well-Being Questionnaire for Participant Four. ................................... .48
Figure 3-12: Sum of Physical and General Well-Being for Participant Four ......................... .49 - Figure 3-13: Gastrointestinal Symptom Rating Questionnaire for Participant Five ................ 53 • Figure 3-14: General Well-Being Questionnaire for Participant Five ..................................... 53 -
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Figure 3-15: Sum of Physical and General Well-Being for Participant Five .......................... 54
Figure 3-16: Gastrointestinal Symptom Rating Questionnaire for Participant Six .................. 58
Figure 3-17: General Well-Being Questionnaire for Participant Six ....................................... 58
Figure 3-18: Sum of Physical and General Well-Being for Participant Six ............................ 59
Figure 3-19: Gastrointestinal Symptom Rating Questionnaire for Participant Seven ............. 63
Figure 3-20: General Well-Being Questionnaire for Participant Seven .................................. 63
Figure 3-21: Sum of Physical and General Well-Being for Participant Seven ........................ 64
Figure 3-22: Gastrointestinal Symptom Rating Questionnaire for Participant Eight .............. 68
Figure 3-23: General Well-Being Questionnaire for Participant Eight ................................... 68
Figure 3-24: Sum of Physical and General Well-Being for Participant Eight.. ....................... 69
I' I~ Figure 3-25: Gastrointestinal Symptom Rating Questionnaire for Participant Nine ............... 73
Figure 3-26: General Well-Being Questionnaire for Participant Nine .................................... 73
.... Figure 3-27: Sum of Physical and General Well-Being for Participant Nine .......................... 74
••• Figure 3-28: Gastrointestinal Symptom Rating Questionnaire for Participant Ten ................. 78
- Figure 3-29: General Well-Being Questionnaire for Participant Ten ...................................... 78
Figure 3-30: Sum of Physical and General Well-Being for Participant Ten ........................... 79
-• LIST OF TABLES
- Table 4-1: Descriptive Statistics (bloating) .............................................................................. 82
- Table 4-2: Ranks (bloating) ..................................................................................................... 82
Table 4-3: Test Statistics (bloating) ......................................................................................... 82
Table 4-4: Descriptive Statistics (abdominal pain) .................................................................. 83
Table 4-5: Ranks (abdominal pain) .......................................................................................... 83
Table 4-6: Test Statistics (abdominal pain) ............................................................................. 83
Table 4-7: Descriptive Statistics (flatulence) ........................................................................... 84
Table 4-8: Ranks (flatulence) ................................................................................................... 84
- Table 4-9: Test Statistics (flatulence) ...................................................................................... 84
Table 4-10: Descriptive Statistics (diarrhoea) .......................................................................... 85
- Table 4-11: Ranks (diarrhoea) ................................................................................................. 85 - Table 4-12: Test Statistics (diarrhoea) ..................................................................................... 85
Table 4-13: Descriptive Statistics (constipation) ..................................................................... 86 - Table 4-14: Ranks (constipation) ............................................................................................. 86 - Table 4-15: Test Statistics (constipation) ................................................................................. 86
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CHAPTER ONE
REVIEW OF RELATED LITERATURE
1.1 Jlrohlem Statement
Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder with a prevalence of
approximately 1:-l-22% of the general population (Nicholl et al, 2007: Bellini et al, 2005). It is the
most frequently encountered gastrointestinal disorder in the western world (Forbes & Hunter, 2007).
Only 10% of individuals that suffer from IBS seek medical attention (Palmer et al, 2002). This was
found to be due to disillusionment with the limited treatment options that are available (Wilson ct al,
2004 ). Sufferers of IBS have a significantly reduced quality of life and greater absenteeism from
work than the general population (Wilson et al, 2004). In a study conducted by Bengtsson et al
(2006 ), women with IBS complained of feeling misunderstood and receiving little sympathy and
support from their family and health workers. Despite its prevalence, the aetiological origin of IBS
is not well understood (Bellini et al, 2005; Snelling, 2006). The research conducted on IBS thus far
is inconclusive and results are often contradictory. There is therefore a need for further research into
IBS in order to find better and more effective ways to treat and manage this poorly understood
syndrome.
IBS is considered a functional gastrointestinal disorder (FGID). This implies that clinical
investigations do not reveal pathological findings. It affects the large bowel (Drossman, 2006).
Features of IBS include abdominal pain, abdominal distension, altered bowel motility, increased
rectal mucous, and feelings of incomplete defaecation (Palmer et al, 2002). The most commonly
experienced complaint is recurrent pain or discomfort in the abdomen. This pain is usually described
as cramping or colicky, and is commonly concentrated in the lower region of the abdomen and
ameliorated by defaecation (Bickley & Szilagyi, 2003). Abdominal distension tends to become
worse as the day progresses, and does not seem to coincide with abnormally increased intestinal gas.
There is variability in bowel habits, but most people with IBS exhibit a pattern of alternating
diarrhoea and constipation (Palmer ct al, 2002).
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Despite the benign nature of IBS, symptoms are similar to more serious bowel diseases, namely
inflammatory bowel disease (Crohn 's disease and ulcerative colitis) and colon cancer (Forbes &
Hunter, 2007). Those affected by IBS are usually between the ages of 20 and 40 years and the ratio
of women diagnosed with IBS being higher than men, the ratio being three to two respectively
(Kumar & Clark, 2002). Clinical examinations are used to exclude the possibility of organic
diseases. Beyond 40 years of age particularly, organic disease must be suspected, investigated and
excluded (Longmore et a!, 2007).
The diagnosis of IBS is one of clinical exclusion of all other possible pathology. Full blood count,
erythrocyte sedimentation rate, and colonoscopy are indicated especially in people over forty years
of age or those with rectal bleeding, weight loss, nocturnal diarrhoea and/or abdominal pain,
anaemia and fever (Forbes & Hunter, 2007). The Rome Criteria III defines guidelines to assist in the
accurate diagnosis of IBS. Diagnosis is made on the basis that the patient has experienced within the
time frame of six months, at least three months of recurrent episodes of abdominal pain or
discomfort associated with two or more symptoms of either relief after defaecation, and/or a change
in stool frequency, and/or a change in the stools' appearance (Chang, 2006).
A multitude of factors precipitate the symptoms of IBS. These include eating certain foods, stress,
psychological disturbances and the hormonal fluctuations of the female menstrual cycle (Ohman &
Simren, 2007). Individuals diagnosed with IBS exhibit higher anxiety levels and are more
predisposed to depression. Ten to twenty percent of people with IBS suffer from food intolerances,
with wheat or lactose intolerances being especially common (Kumar & Clark, 2002). Recently,
research has indicated that IBS may be related to the dysfunctional interaction between the 'brain
gut' axis and other influencing factors (Ohman & Simren, 2007). The visceral sensitivity within the
bowel of people with IBS seems to be hypersensitive to distension (Keshav, 2004 ).
The options for IBS treatment are limited allopathically, due partially to the fact that the exact
aetiology of IBS cannot be iclentifiecl (Ohman & Simren, 2007). Lifestyle and dietary modification
has proved important in the management of IBS (Simren et al, 2007). Conventional medicine offers
medication that is aimed at providing symptomatic relief and has not provided a satisfactory
treatment for IBS (Tkachuk et a!, 2003). Other options include psychological treatment, herbal
medication and homoeopathy.
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1.2 Irritable Bowel Syndrome
1.2.1 Symptoms
The symptom complex of IBS is multifaceted. lt is therefore difficult to differentiate functional
gastrointestinal disorders !rom organic pathology (Ow yang, 2005 ). The most common! y
experienced symptoms are abdominal pain or discomfort, altered bowel movements, gaseous
symptoms, and symptoms of the upper gastrointestinal tract, such as nausea, vomiting and
dyspepsia.
Abdominal pain/discomfort
The Rome Criteria III includes abdominal pain/discomfort as the primary clinical feature for the
diagnosis of IBS. The severity and location of the pain/discomfort varies, but the hypogastrium is
the most common location. Pain/discomfort is also experienced in the left and right sides of the
abdomen, as well as in the epigastric region. The quality of the pain is often referred to as cramping
which is episodic in nature or associated with a constant aching discomfort. Factors that worsen the
pain/discomfort are emotional stress, eating, and in females, the premenstrual and menstrual periods.
The passage of stool or flatus alleviates pain/discomfort. The pain is not responsible for loss of
caloric intake and it very rarely (only in severe cases) prevents sleep or wakes the individual at night
(Owyang, 2005). Pain in IBS is a multidimensional feature and the experience of it and its effect
was investigated by Lackner, Jaccard, and Blanchard (2005), who found that the sensation of pain
and resultant illness behaviours in individuals with IBS was shown to be influenced by age and
gender.
Altered bowel movements
Bowel habit alteration is the most distinguishable clinical feature in IBS. A pattern of alternating
constipation and diarrhoea is the most common. Either constipation or diarrhoea predominates and
may be experienced episodically. When constipation is primary, stools are narrowed and hard. The
stools are difficult to pass and the majority of individuals with IBS complain of a sense of
incomplete evacuation and a repeated ineffectual desire to pass stool. Constipation may last for
weeks or months, interrupted by brief episodes of diarrhoea. Diarrhoea predominant IBS JS
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characterised by small volume stools that are less than 200m] and sometimes accompanied by
mucous. The diarrhoea is aggravated by emotional stress and/or eating. Nocturnal diarrhoea, rectal
bleeding (with the exception or haemorrhoids), weight loss, and malabsorption are not features of
IBS, but rather those of inflammatory bowel disease or cancer (Owyang, 2005).
Gaseous Symptoms
Individuals with IBS often complain of gas related symptoms such as abdominal distension,
bloating, flatulence, and eructations (Owyang, 2005). According to Hasler (2007), in an
investigation relating to IBS, 60% of IBS sufferers rated bloating as 'the most bothersome
symptom', and it more often troubled women, especially during menstruation. Stress has been
shown to aggravate bloating in IBS. These gaseous symptoms are thought to be the result of altered
gas transit, increased production of gas, increased perceptive sensitivity to normal gas amounts in
the intestines, or 'abnormal somatic muscular activity' in the wall of the abdomen (Hasler, 2007).
Studies have shown that eructations are the result of gas that is refluxed from the distal to the
proximal intestine (Owyang, 2005).
Upper gastrointestinal symptoms
Nausea, vomiting, and dyspepsia are additional symptoms experienced by some individuals with
IBS. Functional dyspepsia seems to be prevalent and overlaps with the symptoms of IBS.
Abnormalities in the motility of the small bowel during the waking hours and a difference in motor
pattern nocturnally as compared with healthy controls has been recorded in IBS patients (Owyang,
2005).
1.2.2 Aetiology
The aetiological origin of IBS is not well understood. It has been proposed that several factors may
be responsible. Amongst the postulates proposed are disordered regulation of the 'brain-gut' axis,
genetic factors, psychological factors, visceral hypersensitivity (and the precipitating influence of
dietary foods), gastrointestinal motility, hormonal and neuropeptide influences, inflammatory
changes (Ohman and Simren, 2007) and food intolerances. These factors will be discussed in detail
below.
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Hrain-gut Axis
The brain-gut axis is comprised of three components of the nervous system: the autonomic system,
the central nervous system, and the enteric system (Van Odenhove et a!, 2004 ). Positron emission
tomography (PET) and functional magnetic resonance imaging (fMRI) have been used in studies in
order to gain further understanding into the significance of the thalamus, anterior cingulate cortex,
insular cortex, and prefrontal cortex in the activation of pain processing in individuals with IBS in
comparison with healthy individuals. The results showed an increase in activity in the thalamus,
insular cortex, and the prefrontal cortex in IBS patients. Interestingly, the insular cortex, prefrontal
cortex and cingular cortex also play a role in the regulation of mood, showing that there is an
integration of both the emotional and visceral sensory information at this level in functional
gastrointestinal disorders (Van Odenhove et al, 2004). The majority of study results concluded that
IBS sufferers may have increased activity in their sensory areas during visceral distension which
leads to a heightened perception of visceral pain (Owyang, 2005). In addition, affect and recognition
of the pain involved the cortical region. It has been demonstrated that there is a difference in brain
region activation in male and female IBS sufferers. Psychological states influence brain activity and
therefore play an important role in the modulation of brain activity patterns. Treatment of IBS has
resulted in changes in certain regions of the brain. Despite the discrepancies in the results of studies
conducted into the role of brain-gut dysregulation in IBS, it can be concluded that IBS is associated
with alterations along the brain-gut axis (Ohman and Simren, 2007).
The autonomic nervous system (ANS) is responsible for the mediation of the sympathetic as well as
the parasympathetic pathways of the central nervous system (CNS) in its communication with the
gut. This is achieved via the hypothalamic-pituitary-adrenal (HPA) axis and by the modulation of
the enteric nervous system. Studies have been inconsistent, but have frequently reported that
individuals with IBS have an increase in sympathetic activity and a decrease in parasympathetic
activity in comparison with healthy individuals. Gender differences in ANS responses to visceral
stimuli have been reported in individuals with IBS. The role of the HPA axis in IBS is still unclear
as the results vary. Reports suggest a link between the HPA axis and its response under stress, with
the release of pro-inflammatory cytokines. It is a well known fact that corticotrophin releasing factor
has effects on the sensory and motor functions of the colon. This is especially relevant when
analysing the relation of gastrointestinal function and stress (C)hman and Simren, 2007).
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The role of genetics
Studies investigating the importance of genetics in the pathophysiology of IBS show that there is
some genetic contribution. The serotonin transporter gene shows some genetic variants in people
with IBS. These polymorphisms may assist in distinguishing between subtypes of IBS and assessing
treatment response. In another study, alpha2 adrenergic receptor polymorphisms showed a relation
to bowel habits in IBS and somatic symptoms that are particularly severe. In addition, cytokine gene
polymorphisms were found to be more common in IBS. This provides some support to the proposal
that the aetiology of IBS may be related to immune activity that is genetically determined (Ohman
and Simren, 2007).
Psychological Factors
Opinion is divided as to the role of psychological factors in IBS. There is some _debate as to whether
gastrointestinal symptoms are the result of psychological factors or whether the gastrointestinal
symptoms are responsible for the psychological aspects. Studies are inconsistent (Ohman and
Simren, 2007). Taken overall, studies suggest that psychological factors may not only determine the
severity of IBS symptoms, but may also be a possible trigger for further episodes (Holtmann, 2004 ).
The role of a history of personal abuse in the development of IBS is controversial. Women who
have experienced abuse more often suffer from physical conditions that are chronic. Somatisation
due to abuse has been proposed as a factor in the pathogenesis of IBS (Lewis, 2001 ). A large
number of individuals suffering from IBS have concurrent somatisation disorder (Ohman and
Simren, 2007). Psychological factors seem to be the link between abuse and the development of
FGID (Olatunji et al, 2004).
A high incidence of co-morbidity of psychiatric disorders and IBS has been found, especially related
to mood (specifically depression) ancl anxiety disorders (Olden, 2006: Olatunji et al, 2004).
Resultant negative and destructive thoughts and behaviours influence the way 111 which the
individual experiences and copes with their symptoms (Ohman and Simren, 2007: Olden, 2006).
According to Olatunji ct a! (2004), 75% of individuals seeking medical assistance for IBS complain
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of associated psychiatric symptoms. Of these individuals, 4WYr) had a psychiatric disorder. lBS
seems to precede the onset of psychiatric illness.
There are several hypotheses proposing that: psychiatric symptoms are not the cause, but the
consequence of gastrointestinal symptoms (somatopsychic hypothesis): that treatment seeking
behaviour is related to a personality type that suffers more often with psychiatric problems,
defective coping abilities, and illness behaviour (seU~selection hypothesis): and that the
inappropriate diagnostic criteria hypothesis proposes that the vague diagnostic criteria for IBS may
result in the inclusion of more individuals diagnosed with co-morbid psychiatric disorders (Olatunji
et al, 2004).
Visceral Sensitivity
Perceptive sensitivity with regard to the viscera of the gastrointestinal tract has been found to be
increased in individuals with IBS. This visceral hypersensitivity is reportedly worsened by eating
certain foods, the menstrual cycle, stress, and other psychological factors (Ohman and Simren,
2007). Abnormal visceral pain processing may cause anomalous behavioural and autonomic
responses, therefore further contributing to the symptoms (Van Odenhove et al, 2004).
Studies conducted on the sensitivity of the colon and rectum has revealed that nutrients such as
carbohydrates and lipids cause an abnormal hypersensitivity in IBS patients (Ohman and Simren,
2007: Simren et al, 2007). The exact mechanism is unknown, but it is postulated that the
hypersensitivity after food intake is due to an exaggerated gastrointestinal motor and sensory
response (Simren et al, 2007).
The experience of stress and its correlation to the severity of IBS symptoms has been described by
patients and subsequently investigated through research. Results vary, but the common consensus is
that stress plays a role in the modulation of visceral perception (Ohman and Simren, 2007). Studies
reveal that different emotions generate specific endocrine and autonomic responses that affect
bodily functioning, especially the viscera (Van Odenhove eta!, 2004).
7
'1 ..
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---.. -
Psychological aspects as well as quality of life reportedly influence the severity of gastrointestinal
symptoms. Research supports the correlation between psychological factors and visceral
hypersensitivity (Ohman and Simren, 2007).
Women with IBS commonly complain that they experience an aggravation of IBS symptoms in
relation to their menstrual cycle. Studies discovered that women with IBS have increased rectal
sensitivity during menses in comparison with normal controls. It is therefore plausible that visceral
sensitivity in IBS may be influenced by hormones (Ohman and Simren, 2007).
Gastrointestinal Motility
Abdominal distension due to 'excess' gas is commonly accompanied by pain and bloating. It has
been discovered that bloating is related to impaired exogenous gas load transit. The small intestine is
thought to be responsible for the ineffective transit of gas. The reflex activity of the gastrointestinal
tract is altered in IBS, which may contribute to the abnormal handling of gas (Ohman and Simren,
2007: Hasler, 2007).
Hormones and Neuropeptides
Neuropeptides are neuromodulators that influence the release of neurotransmitters and hormones
which act as chemical messengers (Martini et al, 20CH). These molecules are involved in
determining visceral sensitivity and gastrointestinal secretion as well as motility. Serotonin, peptide
YY, neuropeptide Y, cholecystokinin, vasoactive intestinal peptide, motilin, and stress hormones
(such as cortisol) show altered levels in IBS patients (Ohman and Simren, 2007: Balch, 2000). With
regards to neuropeptides, serotonin is the current main focus of investigation with regards to IBS
(Ohman and Simren, 2007).
Serotonin (5HT) is a neurotransmitter which effects the secretion, sensation, and motility of the
gastrointestinal tract. It is stored and synthesised by the enterocromaffin cells in the colon. Serotonin
is released in response to several luminal stimuli. Studies indicate that in IBS patients, serotonin
signalling and availability are altered (Ohman and Simren. 2007). The increased release of serotonin
or diminished serotonin reuptake has been proposed to result in diarrhoea-predominant and post-
"
------• -
infectious IBS (Owyang, 2005). Constipation-predominant IBS may be a resultant feature of the
impaired release of serotonin (Ohman and Simren, 2007).
The role of inflammation
Increased activity of the inflammatory cells of the mucosa is present in about 50% of IBS patients.
There seems to be a correlation between enteric infection and the subsequent development of IBS
like symptoms. Inflammation increases cytokine expression. Enteric inflammation may therefore
determine the visceral sensitisation and hypersensitivity (Drossman, 2006). Aside from
gastroenteritis, mediation of the inflammatory response in IBS is postulated to be effected by
alterations in bacterial gut flora, food sensitivity reactions, susceptible genetic makeup, and
increased gut permeability. The role ofT lymphocyte cells, mast cells, and enteroendocrine cells is
under investigation (Ohman and Simren, 2007).
The importance of decreased or altered bacterial gut flora in the development of the symptoms
attributed to IBS is demonstrated by the increased prevalence of functional gastrointestinal
complaints after antibiotic administration. This is proposed to be clue to an overgrowth of
Enterobacteriaceae and a decreased number of Bij!dohacterium (Ohman and Simren, 2007).
Improvement of IBS symptoms was reported with the use of Bifidobacter infantis, which changed
the ratios of cytokines to normal levels as seen in healthy individuals (Drossman, 2006 ). In research
investigating bacterial strains in the faeces of IBS patients, Clostridium coccoides and B.
catenulatum were discovered to vary in quantity in comparison with healthy individuals. Another
study made use of lactulose breath tests and reported bacterial gut overgrowth. Despite divergent
study results, it is a plausible postulate that IBS patients have altered bacterial gut flora which
increases the immunological reactivity of the intestines (Ohman and Simren, 2007).
The activation of an abnormal immune reaction within the gastrointestinal tract as a result of
ingestion of certain foods has been postulated. The favourable response of IBS patients to
elimination diets demonstrates this. Immunoglobulin E (lgE), immunoglobulin G (lgG) and IgG4
mediation in food sensitivity in individuals with IBS appear to be of importance in the pathogenesis
of IBS (Ohman and Simren, 2007). The Antigen Leucocyte Cellular Antibody (ALCA T) test was
developed in order to detect any intolerances/sensitivities associated with food. It identifies any
lJ
---
----.. -
'hostile' foreign protein and the changes in the sizes of white blood cells. This is an automated
process conducted by a specialised computer (Fell ct al, 1 9t\8)
The contribution of a genetic factor in abnormal inflammatory responses in IBS patients may be due
to abnormal cytokine production as a result of gene mutation. Recent articles suggest that there is a
decreased production of interleukin 10 (IL-l 0) genotype and increased production of tumour
necrosis factor a (TNF-a) genotype in IBS patients. Therefore, genetic susceptibility may prove to
be a contributing factor in the pathogenesis of IBS (Ohman and Simren, 2007).
In healthy individuals, the epithelial lining of the gastrointestinal tract is permeable primarily to
small particles. Studies have found that this semi-permeable barrier is defective in IBS patients. The
increased gut permeability causes a higher exposure to local antigens, which results in a intestinal
immunological reaction. This is particularly true for post-infectious IBS, which develops after an
acute gastrointestinal illness (Ohman and Simren, 2007). It commonly occurs in young women and
is thought to be caused by Campylobacter, Salmonella, and Shigella. Campylobacter is the most
likely to result in post-infectious IBS (Owyang, 2005). The severity of mucosal inflammation and
higher levels of psychological distress, type of pathogen, duration of illness and female gender
appear to be predictors for the development of post-infectious IBS (Corazziari, 2004; Drossman,
2006).
T lymphocytes, mast cells and entero-endocrine (EC) cells may be of importance in the
inflammatory reactions in the gastrointestinal tract of IBS patients. Studies on T lymphocytes in
severe IBS and post-infectious IBS have found that these cells are increased in number. An
increased number of mast cells in the colon is a commonly recognised feature in IBS patients, but
the study results are inconsistent. Increased numbers of EC cells have also been found (Ohman and
Simren, 2007).
Food Intolerances
Intolerances to certain foods may produce the symptoms of IBS. Lactose, high-fat foods, sp1cy
foods, wheat-containing foods are amongst the most commonly identified as intolerances. Sorbitol
and fructose may also cause symptoms associated with IBS. Studies show that by identifying food
intolerances and eliminating the offending foods from the diet, long term relief can be achieved
10
--
----------•
(Snelling, 2006). Alcohol and caffeine have been implicated as precipitators of IBS symptoms
because they act as irritants to the lining of the gastrointestinal tract (Balch, 2000; Simren et al,
2007). In a recent study, there was a reduction in the perception of rectal distension with fibre
(psyllium) supplementation, a possible indication that fibre exerts a desirable effect on visceral
afferent functioning (Owyang, 2005). Coeliac disease exhibits gaseous symptoms that are similar to
IBS (Hasler, 2007).
It is important to distinguish between 'roughage' and fibre. 'Roughage' is insoluble in water and has
a coarse texture which may irritate the lining of the gastrointestinal tract. Fibre is water soluble, and
provides bulk and hydration to the stool (Till et al, 2006). A high fibre diet which includes
vegetables, fruit, legumes, and whole grains is recommended for sufferers of IBS (Balch, 2000;
Owyang, 2005). Water soluble fibre provides stool with bulk due to its water holding abilities and
increases colonic transit time. This seems to have a modulating effect on bowel movements both in
constipated patients and those with diarrhoea, although studies conducted show varying results
(Owyang, 2005). According to a review conducted on the efficacy of different fibre types (soluble or
insoluble) in the treatment of IBS, soluble fibre (psyllium or ispaghula, oat bran, barley, peeled
apple) was found to have a favourable effect on IBS symptoms. Insoluble fibre (wheat bran, corn)
seemed to worsen the symptoms in some cases, especially when coarsely ground (Simren et al,
2007). Fibre supplementation and stool-bulking agents may ease evacuation by softening the stool,
but can in excess lead to diarrhoea and bloating (Bharucha, 2007). Suitable dietary fibre may
therefore offer an effective treatment option for individuals with IBS (Owyang, 2005).
1.2.3 Diagnosis
Due to its heterogeneous nature, the diagnosis of IBS is made on the basis of symptom-based criteria
(Rome Criteria and Manning Criteria), as well as a diagnosis by exclusion of other diseases with
similar symptoms (Longmore, et al, 2007: Owyang, 2005).
The inability to define FGIDs and the lack of pathological findings, led to the creation of the
Manning Criteria (Olatunji et al, 2004). Greater understanding of IBS found the Manning Criteria
too restrictive and this then led to the development of the Rome Criteria. The Rome Criteria has
been further modified as our knowledge of IBS has grown. There is a general consensus that the
J 1
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----
------
Rome III Criteria must currently be considered when a diagnosis of IBS is made (Drossman, 200o).
The Rome III Criteria states the following:
During at least three of the past six months, there has been recurrent abdominal pain or discomfort
associated with two or more of the following (Chang, 2006 ):
• Pain/discomfort that improves with the passage of stool
• A change in stool frequency since onset
• A change in appearance of stool since onset
The Rome Criteria III further provides a defined adjunct to investigations that excludes organic
diseases as the symptom aetiology. This then allows for a confidant and precise diagnosis of IBS. It
is extremely important to investigate all patients presenting with IBS-like symptoms, irrespective of
their age (Bharucha, 2007). According to Longmore et al (2007), patients under 45 years of age
presenting with IBS-like symptoms should undergo blood works including a full blood count,
erythrocyte sedimentation rate, liver function tests, coeliac serology, urinalysis and possibly
sigmoidoscopy with rectal biopsy. Patients older than 45 years should undergo colonoscopy or
barium enema in addition, to exclude organic changes. When diarrhoea-predominant symptoms
occur, stool cultures, B12/folate, thyroid stimulating hormone (TSH) and anti-endomyosial
antibodies should be investigated in addition to the standard investigations (Longmore et al, 2007).
A good patient history including pam characteristics, bowel habits, dietary and drug related
histories, as well as family relationship dynamics and emotional state should be given attention
(Bharucha, 2007). If food intolerances or sensitivities are suspected, an ALCAT test can be
performed. This test can help to identify offending food/s which subsequently can be eliminated
from the diet (ALCAT, 200S). Serologic tests for coeliac disease involve tissue transglutaminase or
endomysia] antibodies. These tests are conducted when ethnic background and case history alludes
to this predisposition (Hasler, 2007).
Danger signs that are not related to IBS include unexplained weight loss, nocturnal pain and/or
diarrhoea, rectal bleeding, anaemia and fever (Forbes & Hunter, 2007; Longmore eta/, 2007).
12
.....
,.~
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1.3 Current Treatment Options for IBS
General Approach
The nature of IBS is that of alternation between periods of relapse and remittance (Palmer et al,
2002). The general care guidelines are aimed at providing an integrative approach to the patients'
symptoms based on the severity of their symptoms and a good doctor-patient relationship
(Drossman, 2006). In a review of treatment options by Snelling (2006), it is suggested that all
treatment should be individualised. The first steps of patient management in IBS cases are
reassurance, patient counselling and education on their condition (Bellini et al, 2005; Bharucha,
2007). Dietary advice and lifestyle management may be sufficient to provide satisfactory relief
(Snelling, 2006; Owyang, 2005). Regular physical exercise improves bowel functioning and
decreases stress levels (Bharucha, 2007). Other treatment options may also include the use of
pharmacological drugs, psychological treatment, herbal and homoeopathy medication.
1.3.1 Dietary Management
The importance of dietary factors in IBS cannot be overlooked. Dietary management should
therefore be regarded as a first line treatment in IBS patients (Simren et al, 2007). Dietary guidelines
for IBS recommend a normal, varied diet. Small, regular meals should be eaten throughout the day
(Beyer, 2000). Postprandial abdominal symptoms may be decreased by a low-fat diet (Bharucha,
2007). Suspected food intolerances (most commonly due to fatty foods, spicy foods, wheat
containing foods such as bread and cereals, lactose, and dairy products) may be identified by
elimination diets and the ALCA T test, and improved by reducing the intake of the offending food
(Balch, 2000; Snelling, 2006). Drossman (2006) suggests that a food diary might be helpful in
identifying foods that aggravate IBS symptoms. The reduction of excessive alcohol and caffeine
may improve symptoms (especially in diarrhoeal symptoms) as they are irritants to the lining of the
stomach and colon (Balch, 2000; Simren et al, 2007). Some patients may benefit from limiting
sorbitol and fructose (Lewis, 2001; Simren et al, 20Cl7). An increase in soluble fibre and a decrease
in insoluble fibre ('roughage') may also be helpful in decreasing IBS symptoms (Till et al, 2006 ).
''"' I !>I
-.....
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1.3.2 Pharmacological treatment of IBS
Conventional medicine offers medication that is aimed at providing symptomatic relief of IBS, but
is also associated with the risk of side-effects (Tkachuk et al, 2003). The pharmacological options
for IBS treatment are limited, clue partially to the fact that the exact aetiology of IBS cannot be
identified (Ohman & Simren, 2007). Drugs such as antispasmodics or anti-cholinergics are
prescribed to relieve abdominal pain, anti-diarrhoeals to stop diarrhoea. Anti-diarrhoeals can cause
flatulence and constipation (Dreyer, 2005). Amitriptyline, an allopathic drug used to treat
depression, is sometimes prescribed in low closes to reduce visceral sensation and abnormal bowel
motility. Side-effects include dryness of the mouth and drowsiness. Agonists of 5-HT4 may also be
used for constipation-predominant IBS (Palmer et al, 2002; Kumar & Clark, 2002). Drossman
(2006) suggests the use of pharmacotherapy only when symptoms are moderate to severe and
associated with impairment of daily functioning or distress.
Antispasmodics
Temporary symptomatic relief of painful intestinal spasms with the use of anticholinergic drugs has
been noted, though research provides varying results as to their efficacy (Owyang, 2005; Bharucha,
2007). Constipation may be provoked and/or aggravated by antispasmodics (Snelling, 2006) .
Antidiarrhoeal drugs
In diarrhoea-predominant IBS, Loperamide® decreases intestinal transit as well as increasing the
absorption of intestinal water and ions. The improvement is limited to decreasing bowel movement
and normalising stool consistency. It has no effect on pain in IBS. Loperamide® use is therefore
recommended only for painless diarrhoea in IBS or for the temporary control of diarrhoea that
would otherwise cause social restrictions (Snelling, 2006; Bharucha, 2007). Drug dependency and
drug side effects both become a problem (Balch, 2000).
14
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-
-
Antidepressant drugs
Low dose tricyclic antidepressants (TCA) such as Amitriptyline® may provide relief from
symptoms such as abdominal pain, diarrhoea and bloating by modulating the 'brain-gut' axis
(Bharucha, 2007; Palmer et ul, 2002). For IBS patients suffering from chronic pain with or without
anxiety and depression, antidepressants are recommended (Drossman, 2006 ). Studies have shown
that patients who suffer predominantly from severe pain and diarrhoea benefit most from the
treatment with TCAs (Palmer et al, 2002). Caution must be taken as these drugs may have severe
side-effects (Snelling, 2006 ). Anxiety and stress are precipitators of IBS symptoms and therefore
attention has been focussed on serotonin-noradrenergic reuptake inhibitors. These drugs provide a
dual action of analgesia and anti-depressant properties, while selective serotonin reuptake inhibitors
work primarily to reduce associated depression and anxiety, and only play a minor role in pain
alleviation (Drossman, 2006).
Serotinergic drugs
Because serotonin is believed to play an important role in the pathophysiology of IBS, there has
been much interest in the possibility of translating this information into therapeutic interventions for
IBS. Trials conducted on Alosetron®, a selective 5-HT3 antagonist, showed its potential in
alleviating IBS symptoms in women with diarrhoea-predominant IBS. The side-effects and possible
association with ischaemic colitis and the suspected causal relationship with inflammatory bowel
disorder has resulted in the withdrawal of Alosetron® from the market in the United States and it is
not licensed in United Kingdom (Forbes & Hunter, 2007; Palmer et al, 2002).
The 5-HT4 agonist Tegaserod® provided an improvement of symptoms related to constipation
predominant IBS in a number of studies (Forbes & Hunter, 2007; Longmore et al, 2007).
Stool bulking agents
In constipated patients, stool-bulking agents and fibre are used. The efficacy of these agents remains
contested. It is recommended that stool-bulking agents only be used as an adjuvant especially in
painless constipation (Snelling, 2006). In some cases. excessive fibre supplementation may cause - bloating and diarrhoea (Bharucha, 2007 ). - 1:'\ --
--• ---
--------
Probiotic supplementation
Probiotic strains such as Bifidohacterium inf'antis may assist in improving the symptoms of IBS,
most notably bloating (Bharucha, 2007). In a study conducted by O'Mahony et a! (2005), it was
found that only Bifidohacterium infantis in comparison with Lactobacillus salivarus alleviated the
symptoms of IBS. It was concluded that this was clue to its immune-modulating effect,
accomplished by normalising the ratio of anti-inflammatory to a proinflammatory cytokine
(O'Mahony et al, 2005).
1.3.3 Herbal Medication
The relaxing properties of peppermint oil on the smooth muscles of the gastrointestinal tract may be
of benefit in relieving abdominal cramps (Bharucha, 2007; Penner et al, 2005). A study conducted
on the efficacy of peppermint oil taken orally concluded that it could provide effective relief from
the general symptoms of IBS. It did, however cause some adverse effects in some individuals
(Cappello et al, 2007; Griegoleit & Griegoleit, 2005) .
A study conducted to determine the efficacy of Chinese herbal medicine in the treatment of IBS
produced an improvement in bowel symptoms in comparison with the placebo group (Bensoussan et
al, 1998). Some small uncontrolled trials have shown the effectiveness of artichoke leaf extract
(Cynara scolymus) and turmeric (Curcuma longa) in relieving IBS symptoms (Penner et al, 2005).
1.3.4 Psychological therapeutic approach to IBS
The correlation between psychological factors and IBS justifies the use of psychological therapies as
a treatment option for individuals with IBS. The possibilities include cognitive behavioural therapy
(CBT), hypnotherapy, relaxation therapy, biofeedback, and general psychotherapeutic approaches
(Bharucha, 2007; Snelling, 200() ). These therapies are usually reserved for the more severe cases of
IBS. They assist in reducing anxiety levels, promoting healthy behaviour, improving pain tolerance,
and empowering the patient regarding the treatment of their IBS (Dross man, 200() ). However,
studies into the efficacy of hypnotherapy and biofeedback in treating IBS have produced
inconclusive results (Snelling, 2006 ).
lh
'lll!t
Iiiii I
!!lill
-----• -• -
1.3.5 Homoeopathic Treatment
Homoeopathy allows for the treatment of IBS usmg a holistic approach. This implies that each
patient's ailment is addressed and treated individually. This makes homoeopathic treatment of IBS
unique. It deals with not only the bowel symptoms, but also the associated symptoms including the
psychological aspects and individual sensitivities (Gray, 1 998).
1.4 Homeopathy: A Review
Homoeopathy was founded by Samuel Hahnemann 1755-1843 (Vickers & Zollman, 1999). The
word 'homoeopathy' is derived from the two Greek words 'homeo ',meaning similar, and 'pathos',
which means suffering (Vithoulkas, 1993). It is a system of medicine which applies the principle of
'like cures like'. This alludes to the fact that in practice, a remedy that can produce certain effects on
a healthy individual can cure those similar effects when they are related to an ill person (Sankaran,
1995). Homoeopathic medicine stimulates the body's innate defences so that the natural process of
healing can take place (De Schepper, 2006). By addressing all levels of a human being (physical,
emotional and mental), homoeopathy offers a treatment option that is well suited to a multifaceted
disorder such as IBS.
1.4.1 Fundamental Principles of Homoeopathy
The Similimum and the Law of Similars
Hahnemann established that when a substance was given to a healthy person, it caused characteristic
symptoms. When this substance was given to an ill person exhibiting those same or similar
symptoms, the substance acted to combat the illness. This principle became what is known as the
Law of Similars (Castellini, 1999; De Schepper, 2006).
A single remedy that is most accurately matched with the characteristic symptoms of the ill person
is called the similimum. According to Hahnemann (1833), the similimum remedy works by
overpowering the weaker dynamic affection (natural disease) with a stronger, very similar one
(artificial disease), following the therapeutic law of nature. This initiates a defensive reaction from
the vital force, which results in the original disease being eliminated along with the stronger
17
artificial disease (De Schepper, 2006 ). This is possible because the induction of the artificial disease
is transient clue to its infinitesimal quality. Taking note of a person's individual traits, the
homoeopath can uncover a symptomatic picture that is reflected in a specific homocopathic remedy.
lndiviclualisation is the key to bringing about a favourable healing response (De Schepper, 2006 ).
According to Paschero (2000) 'disease is a reaction, which calls for inquiry into the individual
mode qf' re.\ponse of' each patient'.
Provings
Provings refer to the scientific experimentation and evaluation of homoeopathic substances for
therapeutic use. The word 'proving' is derived from the German word 'priif'eng' which translates to
'test'. Hahnemann tested medicinal doses of medicinally used substances on the healthy and
documented their effects. He subsequently used these medicines on the sick.
·~• Single Remedy
----• -• -• --
The use of one remedy at one time is another important principle of homoeopathy. This is based on
the theory that the use of more than one remedy confuses the vital force, and therefore causes
disharmony, an unclear disease picture, counteracting the therapeutic effects, and disordering the
state of illness. When a combination of remedies is administered, it is difficult to accurately
determine what components are acting beneficially and/or unfavourably (DeSchepper, 2006).
Infinitesimal Dose
The infinitesimal dose refers to the fact that homoeopathic medicines are administered in very dilute
forms, often beyond Avogadro's constant (which corresponds to a homoeopathic potency of 12c or
24x). This states that beyond a certain dilution, a substance no longer contains molecules of the
original substance. In general scientific terms, this would make most homoeopathic dilutions inert.
The principle of the infinitesimal dose is comparable to biochemistry's Arndt-Schultz Law which
states that: minimum drug doses stimulate cellular activity, medium doses inhibit cellular activity,
and higher doses destroy cellular activity. Hahnemann realised that minimum drug doses still
elicited a response in ill persons. It is not the remedy that brings about healing, but the body's own
curative power which is stimulated by the remedy (DeSchepper, 2006).
1~
..
• .. •
,,.
Hering's Law of Cure
Constantine Hering noted a pattern of healing and developed a guiding principle to use to evaluate
the process of cure. James Tyler Kent, an American homoeopath, named it Hering's Law. Hering's
Law states that during cure the disease symptoms proceed :fi·om above downwards, from within
outward, .fi·om the most important organs to I east important organs, and in reverse order (~!'
appearance of'.\ymptoms' (Yithoulkas, 1 Y~O). This is of importance to the management of a case as
it guides the homoeopath in evaluating the progress of treatment (De Schepper, 2006; Vithoulkas,
1 ()93 ).
The Vital Force
Hahne mann called the 'healing force of nature' the 'Vital Force' (Sankaran, 1995). It is this force
which animates life and attempts to maintain homeostasis on all levels of being, including the
physical, emotional, and mental levels (Hahnemann, 1833). The 'defence mechanism' is a
component of the vital force which is responsible for healing in disease (Vithoulkas, 1980) .
Individualisation
Homoeopathy views a patient as a whole, not just a physical sum of parts (Sankaran, 1995).
,... Yithoulkas (1980) identifies three levels that human beings comprise of: the physical level, the
emotional level, and the mental level. When applied in practice (in order to evaluate the progress of
a patient) these levels are hierarchically divided from the least important (physical level) to most
important (mental level), although there is a constant interaction between all three levels
(Vithoulkas, 1980). The disease name is of less importance than the particularities and
idiosyncrasies of each individual's manifestation of and reaction to a particular disease. ---• -----
Homeopathy acknowledges that a person is not defined by his/her disease. Instead, the homoeopath
recognises subtleties that make each person's reaction to disease and this allows for individualised
treatment (DeSchepper, 2006).
19
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1.4.2 Homoeopathic Remedies
Remedy Sources
Homoeopathic medicinal substances are derived from a wide variety of sources. These include
animal, plant, and mineral derivatives. Diseased products (nosodes), healthy secretions and healthy
tissues (sarcodes), as well as 'imponderables' (eg. x-rays) provide medicinal sources when prepared
homoeopathically. This affords a vast array of remedy choices (Vithoulkas, 1 993).
Potency
Potentisation ( dynamisation) is the process of liberating latent medicinal properties from a
homoeopathically prepared dilution (Sankaran, 1995). Hahnemann developed potentisation when
he realised that highly diluted substances lost their therapeutic effects along with the desired
decrease in side-effects. By using succussion (shaking) or trituration (grinding) with serial dilution,
he noticed that the therapeutic value of the substance increased without the unfavourable side-effects
of traditional medical doses.
Generally, low potencies are regarded as those that are below Avogadro's constant and high ----------• -• -• -
potencies are regarded as those above Avogadro's constant (Vithoulkas, 1980). According to
Vithoulkas (1980), the choice of potency is secondary to choosing the correct remedy. The correct! y
selected remedy acts irrespective of the potency. The most important consideration therefore is 'the
degree of' certainty' of the prescriber with regards to the case and the clarity of the case. More clarity
and certainty allows for administration of higher potencies (Vithoulkas, 1980).
There are various ways of using potencies and some general guidelines to the selection thereof. Low
potencies should be administered initially when patients have weak constitutions, in hypersensitive
patients, in patients with serious pathological conditions or malignancies, and in children and the
elderly. The use of lower potencies minimises overstimulation of the already weakened defence
mechanism, which would otherwise result in aggravations. When a strong vitality and characteristic
symptoms are obvious in a case, a high potency may be given (Vithoulkas, 1 993 ). The clarity of
symptom expression is most important when administering a high potency (Sankaran, 1 095).
According to Vithoulkas (19t-;O), the correct remedy will act curatively in any potency. Luc De
20
••
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-------
Schepper (2006) refers to Hahncmann 's three-part guideline for potency selection. It includes the
consideration of: the 'nature (~/ the patient', the 'nature (~('the disease 0 (acute or chronic), and the
'nature of the remedy 0
•
The 'nature of' the patient' (sensitivity) relates to the individuals predisposition and idiosyncrasy.
The 'nature of' the disease 0 relates to the disease state. It includes a differentiation between acute
(high potencies) or chronic disease (low potencies), the stage of advance of disease (early stage
requires high potencies; middle and late stages require low potencies), and the affected level/s
(physical, emotional, mental). The 'nature of' the remedy 0 is related to its action. Slow-acting
remedies should be prescribed in low potencies and fast-acting remedies should be prescribed in
high potencies (DeSchepper, 2006).
Homoeopathic Aggravations
Homoeopathic aggravations manifest as a slight worsening of existing symptoms, as the vital force
reacts in a curative response (Paschero, 2000; Yithoulkas, 19~0). Aggravations are considered a
curative sign because the well chosen remedy has elicited a response from the vital force and must
be monitored, yet allowed to run its course. Homoeopathic remedies may cause aggravations in
hypersensitive constitutions. This is not a curative but a medicinal response (Vithoulkas, 19ts0).
Certain vital reactions can indicate the following;
-An intense aggravation initially, followed by a long-term improvement indicates a good remedy
selection and good vitality
-A lengthy aggravation, followed by either a slight or no improvement, indicates an incurable case
or incorrect remedy
-A brief improvement, followed by a slight aggravation, is indicative of incorrect potency
-lf the patient proves successive remedies, without an improvement, he/she is said to be very
sensitive to the remedies and/or it is a complex case.
21
....
1.4.3 Case Taking
Initial consultation
The initial consultation explores the full range of a person's physical complaint/s, as well as
considering their mental, emotional and general condition. The consultation takes approximately an
hour. It also notes the peculiarities which characterise a person. By noting what constitutes the
individual, the homoeopath can form a picture of the totality of person and apply this knowledge to
finding the indicated remedy (the 'similimum ') and correct potency in accordance with 'similimum'
prescribing. There are four essential components to each symptom described. These are the location,
sensation, concomitants and modalities of each symptom. General factors such as sleep and dreams,
food and environmental preferences, and perspiration are considered. Symptoms presenting
concomitantly with the main complaint and symptoms that alternate are also of relevance. Included - in the consultation is an exploration of a personal and family history of diseases. The diagnosis of - pathology assists in establishing the severity of disease and prognosis of the case, rather than being --• -• --
---------
the decisive factor in choosing a remedy (Vithoulkas, 1980).
Follow-up consultations
The follow-up consultation is a shorter interview which focuses on the patient's response to the
initial prescription. It is very important to recognise the changes elicited by the remedy and to take
into consideration Hering's Law when assessing the effect of the remedy. The remedy must have
elicited the desired, curative effect, even if it is just partial. The homoeopath must understand when
a new prescription is needed and when to 'wait and watch'. When a new prescription needs to be
given, the remedy and potency must be selected on the basis of the information from the follovv·-up
consultation. Attention must be given to changes in energy levels and general sense of well-being.
Symptom changes and the surfacing of new symptoms on all levels must be noted. The above
mentioned aspects must all be considered at the follow-up consultation in order to provide a
treatment regime that is most suited and effective for the individual (Vithoulkas, 1980).
"Y)
----------
-
-----
Repertorisation
The Homoeopathic Repertory and Materia Medica are reference sources for the choice of remedy.
The Repertory lists symptoms and associated remedies, and the Materia Medica contains a detailed
description on the characteristics of each remedy. The process of finding the similimum remedy
involves a detailed analysis of the critical complaint as well as th~ person's individual and peculiar
nature, consisting of symptoms from the mental, emotional, and physical levels (Sankaran, 1995).
The analysis of a homoeopathic case is a systematic process of referral to the Homeopathic Materia
Medica and Repertory in order to accumulate a list of possible remedies. The list of remedies
reflects the symptoms that are present in the case. The repertorisation process is used as a guide, but
the ultimate choice of remedy is left to the knowledge of the prescriber. Once this is completed, the
most appropriate remedy can be selected from a Homoeopathic Materia Medica (Vithoukas, 1980).
Dosage and repetitions
The factors determining the frequency of remedy administration are:
• Remedy potency
• The remedy's purpose (therapeutic or constitutional)
• The time the remedy takes to bring about a reaction from the patient's body. This is determined
in by the patient's constitution and Vital Force, the action of the indicated remedy, the strength
of the disease, and obstacles to cure (DeSchepper, 2006).
1.4.4 Case management
Homoeopathic case management includes the task of analysing and understanding the patient's
progress or lack thereof. Knowledge, patience and sound judgement are required throughout the
process of treatment.
There are six fundamental principles that govern homoeopathic case management after prescription.
These principles are:
• Do not interfere if a patient is feeling better
23
•
""
,, 11111
"lilt
--------
• Only change prescription when the prev1ous one has stopped working and only prescribe a
second remedy when there is a clear symptom picture
• If old symptoms return anclthe patient is still generally improving, wait and do not prescribe
• If skin symptoms appear associated with a general improvement, do not prescribe
• Residual, minor symptoms should not be prescribed for
• If symptoms follow Hering's Law, for example by movwg from above downwards, a
prescription is unnecessary (Vithoulkas, 19~0)
1.4.5 Homoeopathy and IBS
Two studies have been conducted at the University of Johannesburg (when it was Technikon
Witwatersrand). The aim of both studies was to identify a safe and effective alternative treatment for
IBS sufferers using homoeopathic remedies.
Schultz (1999) undertook a study on the efficacy of the homoeopathic remedies Argentum nitricum
6CH and Lycopodium clavatum 6CH on the treatment of patients suffering from IBS. This study
was a single-blind placebo controlled trial, with sixty volunteers participating. Although the results
of the study were not statistically significant when compared with the placebo, the results were still
qualitatively positive, especially with regards to the remedy Lycopodium clavatum. It is suggested
that a larger sample group, a longer trial period and gender and culturally specific study would be a
positive improvement to the study design.
Robinson (2000) undertook a double blind placebo study to determine the efficacy of the tissue salt
Magnesia pho:-,phorica 6X in comparison with the placebo, in the treatment of IBS. The results
concluded that Magnesia pho:-,phorica was not significantly effective in relieving the symptoms of
IBS. The researcher suggested that a similimum study should be undertaken to assess the
contribution this could offer to the management and treatment of IBS, as the similimum approach
would cover the multifactoral nature of this syndrome and the fundamental principles of
homoeopath y.
24
' ' .
"' IIJ
---------
CHAPTER TWO
METHODOLOGY AND MATERIALS
2.1 Sample and Study Design
A group of ten female volunteers suffering from IBS were recruited by the researcher. Each
participant participated in an initial homoeopathic consultation and a homoeopathic similimum
remedy was prescribed after a baseline of four weeks. The treatment regimes and remedies were
chosen on an individual basis. Follow up consultations were scheduled every four weeks for a
twelve week period. All participants completed the study. This study was conducted over a period
between August 2007 and May 2008.
This study was a qualitative case study. It also included a quantitative component in the form of
numerically graded symptom questionnaires which were completed by all participants and
statistically evaluated at the end of the study
This research was cleared by the Committee for Academic Ethics of the Faculty of Health Sciences
of the University of Johannesburg (Ethical Clearance number 23/07) and the methodology accepted
by the Faculty of Health Sciences Higher Degree Committee (May 2007).
2.2 Recruitment of Participants
Volunteers were recruited using posters, which were displayed at the University of Johannesburg's
Doornfontein campus, in pharmacies and by advertisements placed in local newspapers. Volunteers
were made aware of the twelve week duration of this study. The initial interview established
whether the volunteers met the inclusion and exclusion criteria:
Inclusion:
Only females between twenty and thirty five years of age were accepted to participate.
Each volunteer had to meet the Rome III Criteria for IBS (Appendix A).
25
Exclusion:
Anyone suffering from diagnosed Crohn's disease, ulcerative colitis, bowel cancer or any other
chronic disease was excluded. The participants were made aware of the 'danger signs' of
gastrointestinal diseases and these were also considered in the exclusion and referral criteria.
Pregnancy was an exclusion criterion.
, • Once suitable volunteers were selected using the inclusion and exclusion criteria, each participant
''' partook in an initial consultation where they were requested to sign an Information and Consent
Form (Appendix B).
,... 2.3 Research Procedures -----• --
-
----
The initial consultation consisted of a full homoeopathic interview, including vital signs and an
abdominal examination (Appendix C). No homoeopathic remedies were administered at the first
consultation. Participants were asked to complete a Gastrointestinal Symptom Rating Questionnaire
(Appendix D) as well as a General Well-Being Questionnaire (Appendix E) at each consultation.
The participants were requested to complete the Daily Food Diary (Appendix F) and Daily
Symptom Grading Sheet (Appendix G) in the time period between consultations.
Consultations were scheduled every four weeks and a total of four consultations were held. The
procedure for the follow-up consultations included a follow-up on the initial homoeopathic
interview, assessment of the vital signs and administration of the homoeopathic similimum remedy.
The dosage form was medicated lactose powders. The potency and frequency of administration was
chosen according to each individual case based on the principles discussed in chapter two.
Because diet and food associated intolerances/sensitivities have been implicated as factors
influencing IBS, participants were requested to continue their normal eating habits. Participants
were requested to avoid any other drug therapy during the trial period. Participants unable to avoid
using additional drug therapy were req uestecl to document what they had taken, the amount and how
frequently. Food and drug consumption patterns were monitored and evaluated.
26
,.
--
2.4 Administration of Remedies
Each participant received a homoeopathic similimum remedy at the second consultation. This
allowed each participant to act as their own control for the initial period of four weeks. The potency
and frequency of administration of each remedy was individualised, and chosen under the guidance
of the research supervisor. Potency ranges of 30CH and 200CH were used based on the clarity of
the symptom picture/s and the guidelines referred to in Chapter one. The remedies were prescribed
in the form of powders to which medicated granules had been added for standardization purposes.
Each participant received medication sufficient to last for four weeks, until the next consultation. At
the three follow-up sessions, the prescribed remedy's efficacy was evaluated and prescribed again or
a new similimum was chosen and prescribed with the guidance of the research supervisor.
2.5 Tools Utilised
2.5.1 Gastrointestinal Symptom Rating Questionnaire
The Gastrointestinal Symptom Rating Questionnaire (Appendix D) was used as a graded assessment
of the severity of abdominal symptoms experienced by the participants and was completed at each
of the four consultations. It is a modified version of the Gastrointestinal Symptom Rating Scale
(GSRS) developed by Dimenas, Svedlund and Wiklund in order to measure a wide range of
gastrointestinal symptoms, including IBS (Mapi Research Institute, 2005). It is a self-administered
questionnaire which evaluates the following eleven symptoms:
• Abdominal Pain
• Empty feeling in abdominal area
• Abdominal Rumbling
• Abdominal Bloating
• Wind
• Decreased passage of stool
• increased passage of stool
• Incomplete passage of stool
• Hard stool
• Loose stool
27
------.. --
• Straining with the passage of stool
The grading of symptom severity ranged from 0 (which represented the least severe symptoms) to 3
(which represented the most severe symptoms). The ratings were recorded for each individual
symptom.
2.5.2 General Well-Being Questionnaire
The General Well-Being Questionnaire (Appendix E) was used to assign a graded value to the
psychological well-being of each participant at each of the four consultations. It is a modified
version of the Psychological General Well-Being Schedule developed by the Institute of
Algorithmic Medicine (2006-2007) for the purpose of measuring a person's subjective well-being.
The states which were evaluated are:
• General Health
• Depressed mood
• Anxiety
• Vitality
• Sense of positive well-being
Numerical values ranging from 5 (which represented a great sense of well-being) to 0 (which
represented the worst sense of well-being) were assigned to the following eight questions:
• How are you feeling in general?
• Have you been ill or unwell in the past two weeks?
• Have you felt depressed during the past two weeks?
• Have you felt anxious or nervous during the past two weeks?
• How are your energy levels?
• Have you felt healthy enough to do the things you want/had to do?
• Have you felt worried or upset during the past two weeks?
• How often have you felt happy in the past two weeks?
The numerical value of each symptom was recorded and evaluated.
I,.
--------
2.5.3 Daily Food Diary
The Daily Food Diary (Appendix F) was utilised to monitor the eating habits of the participants and
the use of any other medication, as well as to assess whether certain foods aggravated or precipitated
their IBS symptoms. Participants received the Daily Food Diary sheets at each consultation to
complete daily for the intermittent period between consultations.
2.5.4 Daily Symptom Grading Sheet
The Daily Symptom Grading Sheet (Appendix G) was utilised to assess the daily gastrointestinal
symptoms experienced by each participant and the data was used for the Friedman test. The most
commonly occurring IBS symptoms were evaluated. These were:
• Bloating
• Abdominal Pain
• Flatulence
• Diarrhoea
• Constipation
These symptoms were graded according to numerical values, where 1 was the 'worst' grading and 5
was considered 'excellent/no symptoms'.
2.5.5 Friedman Test
The Friedman test is a non-parametric statistical test that is used for two-way repeated measures,
analysing the variance by ranks (Pallant, 2005).
This test was performed on the Daily Symptom Grading Sheets and took an average of symptom
grades for all participants over the twelve week study period. This allowed for the evaluation of
some research data statistically in order to determine the significance of the results.
---------
·---• -• ---
CHAPTER THREE
CASE STUDIES
3.1 CASE ONE
3.1.1 First Consultation-August 2007
Summary of the Presenting Case
• Indian female
• Year of Birth: 1975
• Married
• One pregnancy, one child
• Occupation: Lecturer
• Resident of Johannesburg
A 31 year old female presented with diagnosed irritable bowel syndrome from which she had been suffering for six months.
She complained of abdominal cramps which she isolated to the epigastric region, especially worse on the right side. The cramping was associated with a dull aching pain in that area which was relieved by the passage of stool. This pain was notably worse during menstruation and ovulation. Sometimes she experienced a burning sensation in her epigastric region, which radiated upwards and was worse without the consumption of breakfast. The participant also suffered from constipation, a problem from which she had suffered since childhood. The constipation regularly lasted for four to five days, and was made worse by a change of environment and travel. Uncomfortable bloating of the abdomen and flatulence which was worse after eating was also experienced. The appearance of her stool was described as round and "pebble-like", sometimes containing mucous. She experienced difficulty in evacuating stools.
She liked order at home and said she procrastinated a lot of the time in all aspects of her life. She complained that her memory had declined and that she would go blank. She was often unable to focus her attention. In times of emotional upset, she withdrew and wanted to be left alone, but did not hold grudges. The participant preferred to avoid confrontation, but was equally willing to speak her mind. Her greatest fears were the safety of her family and getting cancer.
Generally, she lacked a healthy appetite. She craved chocolate and ice cream, but restricted these indulgences due to concern about her weight. She was averse to oily foods and liver. She was thirsty for cold water, which she sipped slowly.
Medical history
• Pre-eclampsia: Caesarian delivery at seven months. Child healthy
---------
Medication
• Trepiline® (tricyclic antidepressant)
Vital Signs and Observations
• The participant seemed restless, irritable and hurried.
• Abdominal examination: The participant appeared to feel uncomfortable at the prospect of
exposing her abdomen. There was tenderness on deep palpation in the epigastric and
hypochondriac regions. Bowel sounds were normal in the right iliac region and Murphy's sign was negative, with a non-palpable liver. Kidneys and spleen were both non-palpable.
• The vital signs recorded were:
o Pulse: 68 beats per minute
o Respiratory rate: 16 breaths per minute o Temperature: 36.6 ac o Blood Pressure: 100/60, right arm, sitting up
3.1.2 Second Consultation-September 2007
The second consultation took place four weeks after the initial consultation and consisted of a brief follow-up on the symptom picture and any changes. The participants' symptoms had remained unchanged during the four weeks baseline period without treatment.
Motivation for the Remedy Selection
The decisive factors favouring this prescription were the following. Constipation due to travel or being away from home; flatulence and bloating after a meal; stools small, hard and difficult to pass; craving for sweets; a forgetful and absent mind, feelings of boredom, and a haughty temperament (Murphy, 1993; Vermeulen, 2001).
Prescription
Lycopodium clavatum 30CH, two powders daily for two weeks, then one powder daily for the next two weeks.
3.1.3 Third Consultation-October 2007
The third consultation took place four weeks after the second consultation. The parttc1pant experienced less bloating and straining with the passage of stool since starting the treatment. The abdominal pains still bothered her occasionally but less than before. She had not experienced cramps and bloating during ovulation, which had been bothering her previously. Her lack of concentration and failing memory was still a cause of concern for her. She felt easily irritated and disorientated at home and at work.
31
----
-
·--• ·-• --.,..
Vital Signs and Observations
• The participant seemed restless and irritable
• The vital signs recorded were: o Pulse: 70 beats per minute
o Respiratory rate: 17 breaths per minute o Temperature: 36.7 oc o Blood Pressure: 90/60, right arm, sitting up
Motivation for the Remedy Selection
There was an improvement in most physical symptoms, but little difference in the mental aspect of the case. It was therefore decided that a higher potency of the same remedy was needed for a short period of time as not to aggravate any symptoms and to bring about a positive change on the mental level. The researcher decided to 'wait and watch' for the rest of the time.
Prescription
Lycopodium clavatum 200CH, one powder daily for five days. For the remaining twenty five days, there was no treatment given
3.1.4 Fourth Consultation-November 2007
The final consultation took place four weeks after the third consultation. The participant had been experiencing diarrhoea with intense cramping pains in the hypochondriac region which started one week prior to the last consultation. She revealed that she had attended a conference during that period and presumed that her digestive troubles were due to a change in diet and the ingestion of fruit juice. She complained of swollen fingers and feet, made worse by the heat. She felt less bloated, but she was constipated without the treatment.
Vital Signs and Observations
• The participant was relaxed and talkative
• The vital signs recorded were: o Pulse: 69 beats per minute o Respiratory rate: 16 breaths per minute o Temperature: 36.7 oc o Blood Pressure: I 00/65, right arm, sitting up
"1'") _..,_
----
--
-------
Case One -Abcun1nat PaFl
-v- Emc·ty fet-ilng .n At lum•nat ar~a l 1
... ------~-- .. ···--·---··
Abcc:-m1nat Rt.:mbilrg
-- - Abc<:m1nat 8lcat1n9
g' "' /:A - -. ............ "'
~ ;: / --+-- \:"'llf":d ., ' '•
.. .. ,, ~/· I
= ~,"'......,.,_ Q ··, - C'ecreas'"d pas sag,. of St•)•)l 'jlo I ,, \ / t'> ~
\ /- -~
----tncr6'aSed pas ;age )f Stool ,.,/
\ •' \
/ \ ,.r"' " --tnccmptet6' pas;age of Stool
0 / \.
i
Consultation I Consultation 2 Consultation l Consultation 4 --·Hard Sk'OI \
~-· lOo-56' Sl.;a;.l I
-It- Stratn1r:o;: 'l'lttl"l :lassa9e or St•)vl '
Figure 3-1: Gastrointestinal Symptom Ratings for Participant One.
Case One
.
I ~
£3 ... ... c -., o_ Q. .;,
+------~~----------------------------------------------
(; l
-r· Hav6'~ou c.;..;.r, 111 or •;n.-lell 1n me past t\r\ft) 'T'~~k;·)
Hav~ felt j.;~·r.::;se.: dunr.) the pas: t'1V1) '-~·!?-?~- 3 ~~
1 -- Havo:- 'f'Ju t~lt an xJC,t; '3 vr n ertGus du nr. 9th~ p :.1s: l'N() "Y~~h's·:
--+- Ho~~ 3r"?y!)ur o?n~rg;~l~v81'3·;
- Hd'df•)u :etth'"altt.; enc:.Jgh t•) •jOCl'" :n tn ~;s y•)u •"4·artf h a~J ro·7·
---,- Ho:l'•~ /')u f81t ,~:um~?d ,::r 1,.;~· ;.:-r :1unnJ th .:- ~ jSt t ·~) v-4·o?~h s·~
,--1-1·:-•·' )ft~r ilJ'd'/•)U ;.,lti~J~·~'i ,junr.g j m ~ c :r;t r .. ~u w.:-~ks·:
Figure 3-2: General Well-Being Ratings for Participant One.
33
Case One
'"" .........
3(:
20:
]ti
5 cii
~5
~ 1:
'5
1)
Cons~..:tsh;n 2
Figure 3-3: Sum of Physical Symptoms and General Well-Being for Participant One. CWell-being should increase and symptoms should decrease)
3.1.5 Overview and Discussion of Case One
The participant responded positively to Lycopodium clavatum. In general, there was an improvement in physical symptoms and a slight decrease in well-being after the administration of the homoeopathic remedy. The participant experienced an exacerbation of physical symptoms as a result of a change in diet in the last week of the study, but her general well-being improved. Individual symptoms fluctuated, each with varying degrees of exacerbation and/or improvements. This is illustrated in Figure 3-1. It shows a definite increase in loose stool, a decrease in straining with the passage of stool, a decrease in incomplete stools, and an initial improvement of abdominal rumbling, which worsened again after the third consultation. Figure 3-2 shows fluctuations in mental/emotional well-being throughout the study period. Figure 3-3 illustrates the relationship between physical symptoms and general well-being over the three months. Generally, the physical symptoms decreased in the second month of the study, after administration of the homoeopathic remedy, with a worsening noted at the fourth consultation. The participant's well-being improved over the two month treatment period, with only a slight worsening noted at the third consultation. In summary, there was an improvement in the overall symptoms and well-being of the participant from the first consultation to the fourth consultation.
3-t
3.2 CASE TWO
3.2.1 First Consultation-August 2007
Summary of Presenting Case
• White Female
• Year of birth: 19i-;4
• Occupation: Student
• Single
• No children
• Resides in Johannesburg
A 22 year old female presented with symptoms of IBS. She had suffered from this for approximately seven years and had been diagnosed by her general practitioner.
She presented with a complaint of abdominal bloating below the umbilicus, which was alleviated by bending forward and applying external heat. The bloating was worsened by standing straight, and the consumption of lentils, wholegrain foods and pastries. This was accompanied by flatulence which was worse at night. She also complained of abdominal pain in the hypogastric region which she described as squeezing. She suffered primarily from constipation, with a passage of stool only once weekly. She described her stool as large, hard, and difficult to evacuate, with a sense of
· • incomplete evacuation after stool. Stress seemed to precipitate all these symptoms .
. i
-------• ... -
Generally, the participant felt tired and stressed with difficulty falling asleep due to an over-active mind. She slept for only four to five hours a night and had to deal with late nights and a very demanding academic and working life. She felt hungry and thirsty, with a craving for chocolates and sweets and a dislike for asparagus and cabbage.
The participant's menstrual cycle was irregular and associated with pre-menstrual syndrome, dysmenorrhoea and a precipitation of the IBS symptoms.
She worried about her academics and the conflict within her family since they opened their own business. She liked company and consolation. She complained of poor concentration due to too much studying, but was still industrious and enjoyed keeping busy despite her apparent exhaustion. Her moods were changeable and related to the level of stress she experienced. The participant described herself as a talkative, helpful and often a judgemental perfectionist. In her limited free time, she enjoyed dancing. She also indulged in alcohol and cigarettes.
Medical History
• • • •
Wisdom teeth removed, aged 22
Tonsillectomy, at 3 months
Suffers from h ypercho !estero laemia
Family history of heart disease and hypercholesterolaemia (maternal)
,,
------• --
Medication
• Cholestego®, Cholestaway® (Soled)
• Vitamin C
• Multivitamin
Vital Signs and Observations
• The vital signs were:
o Pulse: ~0 beats per minute
o Respiratory rate: 17 breaths per minute
o Temperature: 36.7 oc o Blood Pressure: 95/70, right arm, sitting up
• Abdomen was tender on deep palpation along the colon, especially in the hypogastric region.
Percussion revealed some gas in the transverse colon. Bowel sounds were normal in the right
iliac region. Liver not palpable, with a negative Murphy's sign. Kidneys and spleen were not
palpable, nor tender.
3.2.2 Second Consultation-September 2007
The second consultation took place four weeks after the initial consultation. The participant was given her prescription after she revealed that there had been no change in her symptoms since the first consultation.
Vital Signs and Observations
• The participant was hurried and distracted, due to the upcoming examinations
• The vital signs were:
o Pulse: 72 beats per minute
o Respiratory rate: 16 breaths per minute
o Temperature: 36.7 oc o Blood Pressure: 100/70, right arm, sitting up
Motivation for the Remedy Selection
The following characteristics were considered when deciding upon the remedy: reproaches others; sullen and fault-finding; active; likes alcohol; head-strong; difficult concentration; fastidious; abundant ideas in evening in bed; better for being occupied; abdominal disturbances with constipation; bloating with flatulent distension; abdominal pains better for bending double: constipation with ineffectual urging; incomplete and scanty stool; menses always irregular with dysmenorrhoea (Murphy, 1 993; Vermuelen, 20()1 ).
Prescription
Nu;r vomica 30CH, two powders daily for the first two weeks, then one powder daily for the next two weeks .
,,
--------• --
3.2.3 Third Consultation-October 2007
The third consultation took place four weeks after the second consultation. The participant had experienced abdominal pains only twice in the past four weeks, and her bowel movements became more regular, without urgency or straining. She felt restless and was still having trouble getting to sleep and waking in the morning. Her pre-menstrual symptoms hac! improved and she felt less irritable and negative than usual. Her dysmenorrhoea had become "tolerable".
Vital Signs and Observations
• The participant appeared more relaxed and happy
• The vital signs recorded were: o Pulse: 72 beats per minute o Respiratory rate: 16 breaths per minute o Temperature: 36.6 ac o Blood Pressure: 100/60, right arm, sitting up
Motivation for the Remedy Selection
It was decided that the positive improvement in symptoms with the use of Nux vomica justified its further use. The prescription was used as a maintenance dose with the hope of further improvement in the symptoms.
Prescription
Nux vomica 30CH, one powder daily for four weeks.
3.2.4 Fourth Consultation-November 2007
The participant's symptoms had remained improved, especially with regard to her abdominal complaints. She was having regular bowel movements every one or two days and the stools were easy to pass and complete. She was sleeping better and felt that she had more energy.
Vital Signs and Observations
• •
The participant had enjoyed a holiday and was relaxed
The vital signs were:
o Pulse: 72 beats per minute o Respiratory rate: 1~ breaths per minute o Temperature: 36.7 ac o Blood Pressure: 100/70, right arm, sitting up
37
,.
dl
IIHl>
-
... ..
0 +.--Consultation 1
Case Two
~ lncr7as~;pas;ag.;. of St·)Oi
--lnccmpl.;.t.;. pas·;aga of Stool
--HarjStool
Consultation 2 Consultation 3 Consult~ I
Figure 3-4: Gastrointestinal Symptom Ratings for Participant Two.
Case Two
~-:-low 3r.;.·1-:·u f'"-?lin<J•n •?-.;on>?nr'
+---•,....-------+------•---------l ... ---!~1 ·-•-· rid'•;, ,"•)u , .. ~.;-r. •11·:-r Jnwo?llin L'1 o? ~-:l·;t
~N·) ~·-r~~hs ~
, rlav.;. r_,lt :":pr-o-;·;.;..j .ju nn.J tl1o? p.3st f---------...;;:~--...... '---,--------,,._---; ~.{1) Yi8't?k3·)
, l--:-tav.;.you:o?ltaMio~.;;or~7rvous +----Jio----,"'---"*::........---""·-·----~-- ----il dunn<] th,: past l'f••) ''"""~s·:·
' ,.~ '!:_.,_:-i0\4f 3J~\ ... ~.-urB-no?r•::'·l~?v~,·:;')
"~/~/ i ' ~ ·~· -'-I,N-=yc•u r-=lth-e-~lt~.''; <>n•::U<Jh t•:•do::1-= i !tlln.;s·tou wart; h.3dtol 1
j -- -ia-.a fOu '71t r•-xne·j or u~ ;.;.r aunn J .l-------,..--------,---------,-------..;; tf1-? ~ 3Sttt· •) Wl3:8'hS ~·
Cor·;uiUt:on 2 Cor·;ult :r .:.r .1 I
~- -lo~t• ·)fter ,1.~1.:0 l 1)U :o"'lt~""~3PP'i junr·; tho? ~ .. ~st ro.·:•) we.;hs·:
Figure 3-5: General Well-Being Ratings for Participant Two.
38
--
-----
z.c
:c
E 1:; :J (I)
Case Two
Cor:sultct:on : C.)nSL.Itat:~n 1
Figure 3-6: Sum of Physical Symptoms and General Well-being for Participant Two. (Well-being should increase and symptoms should decrease)
3.2.5 Overview and Discussion of Case Two
The participant showed a favourable response to Ntcc Vomica. Although the individual symptoms and well-being records show changeability in severity throughout the study period (Figure 3-4 and Figure 3-5), Figure 3-6 shows a general decrease in symptoms and an increase in the participant's general well-being from the first consultation to the fourth consultation, indicating a clinically relevant improvement. The participant's food diary documented a varied diet, with a general avoidance of foods that aggravated her IBS symptoms.
39
·• ••
-
-
3.3 CASE THREE
3.3.1 First Consultation-August 2007
Summary of Presenting Case
• White Female
• Year of birth: 1lJ~6
• Occupation: Student
• No children
• Resides in Johannesburg
A 21 year old female presented with IBS, from which she had been suffering from since she was 13 years old.
She complained of bloating and flatulence, which she suffered from permanently. It was notably worse at night, from consumption of bread, milk, and oranges and better when she did not eat. It made her want to loosen her clothes. Her bowel habits were irregular, alternating between constipation and diarrhoea. Her stools were exhausting when constipated, with ineffectual straining and dragging pains along the colon, worse on the left. She suffered predominantly from diarrhoea, which was especially worse during periods of stress. Indigestion and gastric reflux also presented a problem.
Generally, she felt lethargic despite getting eight hours of sleep. The participant felt oppressed by heat and the sun, but enjoyed the outdoors and fresh air. She felt thirsty for icy cold water and was averse to bananas and seafood. Her menstrual cycle was irregular, with associated pre-menstrual syndrome, dysmenorrhoea, and a worsening of the flatulence and bloating.
The participant complained of changeable moods as a result of stress and isolated herself from her family and friends. She felt self-conscious about her IBS and explained that it had hindered her in many social aspects. This made her despair and she often felt that she would never recover. She had a fear of public humiliation and therefore was socially reserved, even though she thought of herself as a leader. She described herself as compassionate, understanding and observant, but always taking the back seat which frustrated her.
Medical History
No medical history of significance
Medication
• • Nutri-B® vitamin supplement
-• -• - 40
• -
------• -
Observations and Vital Signs
• The participant was friendly, amiable, and good at expressing herself.
• The vital signs recorded were: o Pulse: 72 beats per minute
o Respiratory rate: 16 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 1 10/80, right arm, sitting up
• There was tenderness on palpation of the right iliac region as well as transversely across from
the right hypochondriac region to the left hypochondriac region. On percussion, gas was present
in the transverse and descending colon. No abnormalities were detected in the liver, spleen or kidneys.
3.3.2 Second Consultation-September 2007
The second consultation took place four weeks after the initial consultation. The participant had been suffering from a period of diarrhoea which had left her feeling depressed and frustrated. Her diarrhoea was excoriating and had been initiated by a stressful few days. Generally her symptoms remained the same since the previous consultation.
Vital Signs
• The vital signs recorded were:
o Pulse: 73 beats per minute o Respiratory rate: 17 breaths per minute o Temperature: 36.6 oc o Blood Pressure: 100/80, right arm, sitting up
Motivation for the Remedy Selection
Pulsatilla pratensi.\· was favoured because of the following aspects which correlated to the entirety of the case: fear of being humiliated; changeable symptoms and emotions with irritability; fresh air improved disposition; generally worse for the sun; a reserved demeanour; abdominal symptoms worse for eating; distension of abdomen and flatus worse at night; constipation alternating with diarrhoea; urging for stool and difficult evacuation; nervousness with diarrhoea (Murphy, 1993; Vermeulen, 2001 ).
Prescription
Pulsatilla pratensis 200CH, two powders daily for two weeks, then one powder daily for the next two weeks.
3.3.3 Third Consultation-October 2007
The third consultation took place four weeks after the second consultation. The participant had had less bloating and flatulence since taking the remedy, and she was having regular bowel movements.
41
The stool was easier to pass and there had been a decrease in the frequency of abdominal pain. She felt good emotionally and was pleased with the improvement of her symptoms, but expressed apprehension at the thought of a relapse.
Vital Signs and Observations
• The participant was anxious and hurried, and looked tired
c The vital signs recorded were:
o Pulse: 73 beats per minute
o Respiratory rate: J S breaths per minute
o Temperature: 36.7 oc o Blood Pressure: 110/70, right arm, sitting up
Motivation for the Remedy Selection
There was an overall improvement in the participant's symptoms and therefore it was decided the same remedy would be administered for another month. Three powders per week were given for two weeks as maintenance doses.
Prescription
, • Pulsatilla pratensis 200CH, one powder daily for two weeks, then three powders weekly for the next two weeks.
II
lliiJ 3.3.4 Fourth Consultation-November 2007
The participant complained of constipation which had started after a few days of diarrhoea. This had been concurrent with a stressful week of writing examinations. She was flatulent and feeling bloated. She "confessed" that she ate irregularly which she noticed aggravated her symptoms. She was anxwus about her trip overseas and was feeling overwhelmed with a desire to "control situations".
Vital Signs and Observations
The participant appeared anxious, but remained friendly and open to questions posed • The vital signs recorded were:
'·""' o Pulse: 75 beats per minute
o Respiratory rate: 17 breaths per minute
o Temperature: 36.4 oc o Blood Pressure: 110/70, right arm, sitting up -
·---- 42 ---
+•!4f
-
------·-
3
0
Case Three
---.~MOmlndl e1oatu-:g
' ' i -c..,creas<?d r-<J·;sage of Stool /
j
i . ....._
Consultation I Consuhation 2 Consultation 3 Consultation 4
; -1ncomp1.:,te passage of Stoo)!
--· Hanj St~·OI
Loose St•)OI
Figure 3-7: Gastrointestinal Symptom Ratings for Participant Three.
5
4
01 .5 .3 ~ ... ... c 0 9- 2
on
Case Three
/
-,it-· H.;ve ·,ou b.een II or ,;m..,ell 1n ttle pc.st !'NO \Net:ks.-:'
Have fe~ depressed dunng the pst t"-'D
""eeks7
H .lve /OU fJ:?It 3f!.,,lous or ner-,;ous dunng :tie pJst l\•.'0 weeks?
I-+--How >re yJur erergy level~?
I ' - H .ave you f.~lt he >lthy enough to .jo ttc~
:h1n1,JS ycou t•r-.lr.t f h:;c to-:'
--H.lve ;ou !~it \•,c;rned or up·:oet dunng :he p >st r.• o ,......,el' s?
--How Jften ~.:lve ';'OU :~~ roaopy dunng :he pa·:;t ~;·•o w?ek-;':'
Figure 3-8: General Well-Being Ratings for Participant Three.
43
---
Case Three
35
E ::I
Cl) 15
10
5
Consultation I (o)fiSUitatiOii 2 ConsL.1t:ot1on 3 ConsultatiOn 4
Figure 3-9: Sum of Physical Symptoms and General Well-being for Participant Three. (Well-being should increase and symptoms should decrease)
3.3.5 Overview and Discussion of Case Three
The participant had a favourable reaction to Pulsatilla pratensis. Figure 3-9 shows a decrease in symptoms with an increase in well-being from the second consultation, after remedy administration. A worsening of both physical symptoms and well-being was noted at the fourth consultation. External factors such as the participant's reaction to stress and dietary changes may have provoked an exacerbation. She had been writing examinations and had planned to travel alone for the first time. The participant's diet contained many gas-forming and sugary foods. Her eating pattern was also irregular. It can be assumed that lifestyle changes, including more regular meals and better stress management would benefit this participant's IBS. In summary, there was an overall improvement in the participant's well-being from the first consultation to fourth consultation.
44
,.
.. ,. ----• ---
-------
3.4 CASE FOUR
3.4.1 First Consultation-September 2007
Summary of Presenting Case
• Indian Female
• Year of birth: 19~5
• Occupation: Student
• Single
• No children
• Resides in Johannesburg
A 22 year old female presented with IBS, with which she was diagnosed four years earlier.
The participant complained of severe periumbilical abdominal cramps that were alleviated by passing stool and hugging her knees to her chest. Stress and fasting made her cramps worse. Her bowel movements alternated between diarrhoea and constipation, though she predominantly suffered from diarrhoea. Loose, copious and excoriating stools were passed after a meal and in the evening, which exhausted the participant.
Generally, her energy levels were low, both physically and mentally. She slept during the day whenever she could and for seven hours every night. Despite this, she felt exhausted on waking. She lacked appetite, and ate small amounts of food at a time. She "admitted" to being concerned about her weight. She was always thirsty, especially for cold water. She had no cravings but was averse to peanut butter.
The participant's menstrual cycle was regular, with a heavy flow. She suffered from dysmenorrhoea and a worsening of the diarrhoea during menstruation.
She worried about doing well in her studies and supporting herself financially. She desired to please her parents and wanted to be acknowledged by her parents for her efforts. She felt excluded from her family and felt that she did not receive the recognition she deserved.
Vital Signs and Observations
• The participant appeared well-spoken with a shy demeanor. She displayed an exaggerated concern about her health and her appearance
• The vital signs recorded were: o Pulse: 76 beats per minute o Respiratory rate: 18 breaths per minute o Temperature: 36.7 oc o Blood Pressure: 90/60, right arm, sitting up
• • The abdominal examination revealed tenderness on deep palpation in the epigastric region and
- the left hypochondriac region. Pronounced bowel sounds were heard on auscultation.
• - 45
• -
..
. , ...
-----• -
Medical History
No medical history of significance
Medication
None
3.4.2 Second Consultation-October 2007
The participant was suffering from episodic morning headaches that she described as "heavy", accompanied by dizziness. There had been no changes in her abdominal and general symptoms since the first consultation, although the .symptoms seemed better since the headaches started.
Vital Signs and Observations
• The participant appeared tired, but in good spirits
• The vital signs recorded were: o Pulse: 73 beats per minute o Respiratory rate: 17 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 90/60, right arm, sitting up
Motivation for the Remedy Selection
When deciding upon the remedy of choice, the following symptoms of the case correlated to the remedy: There was great exhaustion and a tendency to aggravations at night; alternation of pain between stomach and head; anxiety about health and fear of financial loss; thirsty for cold water; periumbilical pain better for bending double; excoriating stools with weakness after diarrhoea; constipation; diarrhoea during menses and after eating (Murphy, 1993; Vermuelen, 2001) .
Prescription
Arsenicum album 30CH, two powders daily for two weeks, then one power daily for the next two weeks.
3.4.3 Third Consultation-November 2007
The third consultation took place four weeks after the second consultation. The participant had not suffered from diarrhoea during the initial two weeks of taking the remedy, but relapsed after a particularly stressful period. She felt less tired since taking the remedy. She also felt less bloated and was having normal bowel movements until the relapse. She still complained of headaches, which she noticed were worsened by the sun. She also noted that the symptoms returned with less severity when she only took one powder daily.
46
,. ill
I lilt
·-
------
Vital Signs and Observations
• The participant was clearly agitated by her headache and was somewhat distracted
• The vital signs recorded were: o Pulse: 75 beats per minute
o Respiratory rate: 17 breaths per minute o Temperature: 36.1-\ oc o Blood Pressure: 90/60, right arm, sitting up
Motivation for the Remedy Selection
The participant had noticed a definite improvement in her symptoms during the first two weeks of treatment. However, when the prescription required only one powder daily, the symptoms returned. This can be attributed to the possibility that Arsenicum album was only a partial similimum. The headaches had become more frequent and pronounced, being the main complaint at the third consultation. Therefore, the case was re-evaluated and Natrum muriaticum was selected. The following Natrum muriaticum attributes were taken into consideration: a sensation of heaviness in the head; symptoms worse for the sun; emotional causes of illness; feels estranged from family; thirsty for cold drinks; constipation alternating with diarrhoea (Murphy, 1993; Vermuelen, 20Cll).
Prescription
Natrum muriaticum 30CH, two powders daily for two weeks, then one powder daily for the next two weeks.
3.4.4 Fourth Consultation-December 2007
The final consultation took place four weeks after the third consultation. The participant had not experienced diarrhoea since taking the remedy. The cramping pains and bloating had been reduced in frequency. She was happy with the overall improvement.
47
----·-
Case Four
0
Consultation 1 Consultation 2 Consultation 3 Consultation 4
i I I : ----Empty fo:-.;11ng 1n A;.j.;'rr"nal ar~a 1
: -- At•jom1nal Boating l '--vY.nd
-lncompi~t~ ps:;ag~ •)I Stool
I
I I I
I I
Stra1n1ng w1t:i pas sag~ of Stoul I
Figure 3-10: Gastrointestinal Symptom Ratings for Participant Four.
Case Four
4 --H.lVe ftJU teen <1 or ~ffil'.lell •n the pag
~NO ·..-·~~ks:'
H :l'<e felt depres.:r.d dunng the ~·>st tv 1)
't~ek5·:
--- H.lVe you f~lt Jm:~ous or nc~!'Vcus dunrg :he p.1st t'l'>il weeks?
-How 1re ycur erergy :e-teis.'
-..- H3Ve :au ielt hellthy enou~h to jo the th•ngs l0U "'<ant / had :a~
-- -1.lVe .'OU f~lt ....:;med Jr UJ:Set •:i' .• nng :hi! p.Et r ..... ,-:.l ·..-~e~l, >-:'
- ciw.• ~rten nave ','Ou f~1t h.;rpy ctunng :he plst !'r·O weeh s?
Figure 3-11: General Well-Being Ratings for Participant Four.
48
-,...,
Case Four
C.:-nsult3t on 2 Cons;;ltat:on.: Consu;tat1on!
Figure 3-12: Sum of Physical Symptoms and General Well-being for Participant Four. (Well-being should increase and symptoms should decrease)
3.4.5 Overview and Discussion of Case Four
The initial prescription of Arsenicum album resulted in an improvement of some physical symptoms, but a worsening of others. In general there was a physical exacerbation with an improvement in well-being from consultation two to consultation three (Figure 3-10 and Figure 3-11). It was decided that Arsenicum album was only a partial similimum and that Natrum muriaticum was more appropriate for the case. The participant responded favourably to Natrum muriaticum. This is illustrated in Figure 3-12, showing a decrease in physical symptoms and an increase in general well-being. Overall, there was a relevant improvement from the first consultation to the last consultation. The participant's diet contained primarily fried and processed foods. It can be assumed that dietary changes (minimise fried foods) may further improve the participant's IBS symptoms over a prolonged period of time.
49
....
--
-------
3.5 CASE FIVE
3.5.1 First Consultation-October 2007
Summary of the Presenting Case
• White Female
• Year of birth: llJ79
• Single
• No children
• Occupation: Student
• Resides in Johannesburg
A 28 year old female presented with IBS.
She complained of abdominal bloating and rumbling, which were worsened by chocolate, bread, dairy, spicy and rich foods. She experienced abdominal cramps in the epigastric region that were alleviated by the passage of stool. She occasionally suffered from diarrhoea with urgency, especially after a rich or spicy meal. Her stools alternated between constipation and diarrhoea, but were predominantly loose .
Generally, she enjoyed wide open spaces and warm environments. She had difficulty sleeping because her brain was constantly active and she therefore felt exhausted both physically and mentally. She was thirsty and craved salty foods, apples, and fruit. She developed headaches from chocolate that she described as a dull aching in the temples.
She described herself as industrious and a perfectionist, with a desire for control and a fear that she would be viewed as lazy or weak. She feared financial loss and failing in her endeavours. She felt depressed if she could not exercise. She enjoyed cigarettes and wine.
Medical History
• Tonsillectomy, age 9
• Wisdom teeth removed, age 18
Medicine
• Femodene®, oral contraceptive
• Essential fatty acid .supplement
• Vitamin C supplement
• Turbovit® vitamin supplement
Vital Signs and Observation
• The patient appeared tense and hurried ancl appreciated the respect of personal space. She came across very passionately about issues that affected her, and voiced her opinions readily.
50
,,.
---
-
• The vital signs recorded were: o Pulse: 7'<J beats per minute o Respiratory rate: 16 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 1 J 0/70, right arm, sitting up
• The abdominal examination revealed that there was tenderness ll1 the epigastric area on palpation. The kidneys, liver and spleen were not enlarged or tender.
3.5.2 Second Consultation-November 2007
The second consultation took place four weeks after the first consultation. The participant had been particularly stressed during the past four weeks and found little time to eat regular meals and exercise regularly. She slept very few hours and felt exhausted as a result.
Motivation for the Remedy Selection
In this case, the mental exertion was marked clue to a prolonged period of studying. The participant also suffered from the following attributes associated with Argentum nitricum: A desire for fresh air; a fear in narrow places; fear of failing and loosing self control; abdominal flatulence and distension, aggravated by a variety of foods, especially sweet things; desire for salt; diarrhoea alternating with constipation; sleeplessness clue to a busy mind (Murphy, 1993; Vermuelen, 2001 ).
Prescription
Argentum nitricum 30CH, two powders daily for two weeks, then one powder daily for the next two weeks.
3.5.3 Third Consultation-December 2007
The third consultation took place four weeks after the second consultation. The participant only experienced the bloating and rumbling in her abdomen occasionally. She was having normal bowel movements and the frequency of diarrhoea had decreased.
Vital Signs and Observations
• •
The participant was less anxious but still exhausted
The vital signs recorded were:
o Pulse: 76 beats per minute o Respiratory rate: 17 breaths per minute o Temperature: 36.6 oc o Blood Pressure: 110/70, right arm, sitting up
.51
--------• -
Motivation for the Remedy Selection
The participant's symptoms had improved on the remedy and therefore it was decided that a repeat prescription was justified. No new symptoms had emerged and the remedy was still working on one powder daily.
Prescription
Arf!entum nitricum 30CH, one powder daily for four weeks
3.5.4 Fourth Consultation-.} anuary 2008
The final consultation took place four weeks after the third consultation. There had been further improvement of the abdominal symptoms and there were now very few episodes of diarrhoea. The abdominal cramps, bloating and distension had improved. General! y, the participant felt more energetic and was sleeping better.
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 77 beats per minute
o Respiratory rate: 16 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 110/80, right arm, sitting up
52
Case Five --Ab•~(.mtnal Pam 3 -- ~-~- ~-- ------------- .. --~ -- " ---------~ -------- "--·------------~--- --·-- ---
-· +- Em,:t·:~ ~~~ling m .At.jom;nal !lr~a
; ;
Abd.:mtnal ~·wmbllll'J
. /
-·-Abd·~mtnal E:i>Jttng : 2 ~~--·------·---Cl !
= -V'•ind i ...
-~ -= -D~·:r.;-3sed passag~ .jf 3t•)•;.l Q
cr. 1 r'\
I - --lncr~aSi!(:l pas;age of St·)•)l i // "
i
~. - :nco;mplete pas·;age of 6tO•)I
~ / ~ /
./ - Haro:: Sto)vl !
0 //
Loose St·;ol - '
Consultation I Consultation 2 Consultation 3 Consultation 4 Stratntng ·Ntth :l3·5s3go? cf Sto:ol
i
Figure 3-13: Gastrointestinal Symptom Ratings for Participant Five .
.•
Case Five
11~-lllil
5 - _ _.- ---------/1/ ----
-HCJ\•; Jre ·1ou te.,.ltng ·n Generll'"'
4
Y/ _,._HJ't~ you been oil or ·;nv.~: I 1n tt'e past
two ,veek>'
H3'-e fe~ jepressed dunng the p.lst 'NO
Cl we~;...~·?
= 3 i X ~--- HJYe you felt ll'xtous or r.~rvOl."i durng I ...
the past ~,'0 w-eeks"? -c: ·c; ;
~HO\"' Jre your enen;; h~··-,.;e-;s? l ; Q. ' 2
I I ll'l . -HJ~e you felt r.eJitt.y enoLqt'l rc ojo tre i
! thtr11:j~ 'ff)L v-,:Jr.t I h.)i) to-:' l
I '·\./ I -H.J\~ 1 ou ~elt \,~~urneri or 1-e~t iunnt; I
t!1e ~1~ r· ·D ·.-eel ;i
--Ho ... ·· ')iter. have you te1t hJ~P':' :!~..<nnq the ;;.J<.l r>u .., ... •e'"!~: z:"
o) I
~: ~'lS:...;.i~ ::l'i:·r ~ Ccnsu: :lt'o)r 2 •:::nsu:!Jh;r 3 ~:~:r:st.il' :.':tl~)r:.!
Figure 3-14: General Well-Being Ratings for Participant Five.
-53 -
-
11111111
--w .•
----
Case Five ;!
35
.....
25
E 2( :::: (I)
1-.::
l(
5
c Cor.sultat10n.: C•)nSultat1on ~
Figure 3-15: Sum of Physical Symptoms and General Well-being for Participant Five. (Well-being should increase and symptoms should decrease)
3.5.5 Overview and Discussion of Case Five
The participant had a favourable reaction to Arsenicum album. Figure 3-13 shows a decrease in severity of most of the physical symptoms. Figure 3-14 shows an increase in general well-being from the second consultation onwards. These improvements correlate to the administration of the homoeopathic remedy. Figure 3-15 shows an overall improvement in the participant's general wellbeing and physical symptoms from the first consultation to the fourth consultation.
The participant's food diary documented that her diet was varied. It included four to five cups of coffee daily and moderate amounts of alcohol. It can be assumed that a reduction in coffee and alcohol consumption (both substances which irritate the lining of the gastrointestinal tract) may limit the participant's IBS symptoms over a prolonged period of time.
54
3.6 CASE SIX
3.6.1 First Consultation-October 2007
Summary of the Presenting Case
• White female
• Yearofbirth: 1981
• Single
• No children
• Occupation: Lodge manager
• Resides in Knysna
A 26 year old female presented with IBS, from which she had suffered for four years.
The participant complained of abdominal bloating that worsened as the day progressed. She suffered from sharp abdominal pains in the left inguinal region, better for sitting erect. She also had constipation with urgency and frequent ineffectual urging. Her stools alternated between a hard and loose consistency.
Generally, she felt exhausted and irritable even though she slept well. Her feet were perspiring and felt hot. She often sought emotional comfort from food and did not feel thirsty. She craved salty foods and meat. She disliked olives.
She feared being alone (she often "feels very alone") and unloved, yet said she needed to be alone • when she felt emotional. She did not like to share her problems. She desired recognition from her
friends and family and went out of her way to be helpful and generous in order to be appreciated. She described herself as industrious, but easily disinterested and bored.
Medical History
• Wisdom teeth extraction,
• Facial reconstructive surgery due to motor vehicle accident,
Medicine
• Nordette® oral contraceptive
• Vital® women's multivitamin
• Vital@ calcium and magnesium supplement
---• -• -• --
Vital Signs and Observations
• The participant talked easily about her symptoms and was friendly
• The vital signs recorded were: o Pulse: 75 beats per minute o Respiratory rate: 16 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 110/80, right arm, sitting up
• The abdominal examination revealed tenderness on palpation in the epigastric region and left inguinal region. The liver, spleen and kidneys were non-tender and not enlarged.
3.6.2 Second Consultation-November 2007
The second consultation took place four weeks after the first consultation. The participant's symptoms had remained the same and there were no additional symptoms.
Vital Signs and Observations
• The vital signs recorded were: ,11 o Pulse: 72 beats per minute
Iii I
Ifill
, ...
----• -• -• --
o Respiratory rate: 17 breaths per minute o Temperature: 36.6 oc o Blood Pressure: 110/80, right arm, sitting up
Motivation for the Remedy Selection
The following aspects are features of Pulsatilla pratensis that correlated to this case: fears being alone; emotional distress and eating problems; irritable; feels alone in the world; silent grief; fastidious; thirstless; distended abdomen with flatulence; ineffectual desire for stool; constipation alternating with diarrhoea; constipation with difficult evacuation; feet feel hot (Murphy, 1993; Vermuelen, 2001).
Prescription
Pulsatilla pratensis 30CH, tw powder daily for two weeks, then one powder daily for the next two weeks.
3.6.3 Third Consultation-December 2007
The third consultation took place four weeks after the second consultation. The participant hac! noticed an improvement in the regularity of her bowel movements, with less urgency and straining. She no longer felt bloated on waking, though she still sometimes experienced it during the day.
56
,,,
,, . lilt
11111•
1111
----• --
Vital Signs and Observations
• The vital signs recorded were: o Pulse: 72 beats per minute o Respiratory rate: 16 breaths per minute o Temperature: 36.7 oc o Blood Pressure: 120/i:)O, right arm, sitting up
Motivation for the Remed~' Selection
There was an improvement in symptoms and thus a repeat prescription was given.
Prescription
Pulsatilla pratensi.\· 30CH, one powder daily for four weeks.
3.6.4 Fourth Consultation-January 2008
The fourth and final consultation took place four weeks after the third consultation. The participant was feeling "a lot better". She had been experiencing fewer episodes of abdominal discomfort. She was less bloated and had noticed that she no longer had foot sweats. She felt happier, more energetic and less irritated and exhausted. The participant felt that she was "handling situations better". Her memory had also improved. She was very pleased with her overall improvement.
Vital signs and Observations
• The vital signs recorded were: o Pulse: 72 beats per minute o Respiratory rate: 17 breaths per minute o Temperature: 36.9 ac o Blood Pressure: 110/60, right arm, sitting up
57
...
,. HI
I' lit;
I· I·
t1~
-----• --
Case Six
I ---- Em::ty fe~lmg :n At.jorr.•nal ar~a
I ···.'<·.
/ -oecr~as~d pas sag~ of Stool
--Hard Stool
0
Consultation 1 Consultation 2 Consultation l Consultation 4 Stram1ng u1th oassag~ oF Stc•)l
Figure 3-16: Gastrointestinal Symptom Ratings for Participant Six .
5 ----- ··-- -···-
4 ~,,
Cl 3 .5
~ ... -c: 0 9- 2 ~
Case Six ·-----·-;:::11·---- ,-----------------,
/ /
'
--+-Ho-.~ lre ;0u t~hng n Geneni? I -..-- H ""~ fOu oeen •II or urM-e•! ·n tte p.lst
two ueek;?
H.l',.~ felt jepre-;;·;ed junng the p.Jst r.•<O \•veet...-;)
-·-... HJve ·lou fel£ ~"'l..".lOUS or r~f'ICL:S dur-ng
the ~.lst r.;o -,..e~ks~ I
-+-::.::~:::::~:: ::: w ,,., • i
thing; 'fO>.; ""Jr.t i hact to7
-.--H.l\.~ 'fOU felt .-.omed or uo>et .~ut'ng
the pc;~ ~:·D ·.·,-e~k:7
:-Hi,)\.~; utt~n h..l'lO: "f'U~ •elt h.:lppy Junng the pst r:•a •··~~k;~
Figure 3-17: General Well-Being Ratings for Participant Six.
58
,I Jill!!!
'".
----
Case Six ,
- J
'"' -'-'
5 15 ... (/)
'•' ")
5
Cvnsultat:on4
Figure 3-18: Sum of Physical Symptoms and General Well-being for Participant Six. (Well-being should increase and symptoms should decrease)
3.6.5 Overview and Discussion of Case Six
The participant reacted favourably to Pulsatilla pratensis. This is illustrated in Figure 3-18, showing a progressive decrease in symptoms and an increase in general wellbeing after administration of the homoeopathic remedy at the second consultation. Figure 3-16 and Figure 3-17 show fluctuations in the individual symptoms and well-being throughout the study period, but also reveal a trend of improvement. The overall improvement illustrated in Figure 3-18 from the first consultation to the last consultation must be considered.
The participant's food diary documented that a large portion of her diet contained processed foods, with virtually no fresh fruits or vegetables included. Coffee and alcohol consumption were moderate. A decrease in alcohol and coffee consumption (both irritants to the lining of the gastrointestinal tract) and a more nutritionally balanced diet may improve the participant's energy levels and IBS symptoms over a prolonged period of time.
59
I ill It
3.7 CASE SEVEN
3.7.1 First Consultation-October 2007
Summary of the Presenting Case
• White female
• Year of birth: 1983
• Single
• No children
• Occupation: student
• Resides in Johannesburg
A 24 year old female presented with IBS.
She complained of colicky-type abdominal pain in the left iliac region, which was worsened by stress, anxiety, heavy meals and alcohol. The pain was relieved by passing stool and pressure. There was abdominal rumbling, which was constant. She often experienced a gnawing, burning sensation in the epigastric region. Diarrhoea with flatulence alternating with constipation was another complaint. She predominantly suffered from diarrhoea with abdominal spasms during the passage of stool. The diarrhoea was worse during her menses. Stress and anxiety triggered vomiting.
The participant was vegetarian, a decision she made ten years prior due to her disgust at the cruelty of the meat trade. She was exhausted as she tried to balance her working schedule and studying, and as a result only got an average of four hours sleep. She generally felt the cold easily. She craved cheese, pasta, and chocolates (which initiated migraine-type headaches, worsened by strong smells and tobacco, and alleviated by rest).
The participant feared dead things. She worried about her mother who threatened suicide and was at times emotionally abusive towards the participant. Her finances were also a concern. She enjoyed smoking cigarettes and drinking wine because it served to ease her nerves.
Medical History
No medical history of significance
Medicine
The participant was taking no medication
- Vital Signs and Observations
- • The participant was often hurried and distracted, but was easy to talk to and verbally expressive.
• The vital signs recorded were:
- o Pulse: 78 beats per minute
- o Respiratory rate: 17 breaths per minute o Temperature: 36.5 oc - 60
• --
--
.. -• --
o Blood Pressure: 90/60, right arm, sitting up
• There was tenderness of the entire abdomen on deep palpation, especially worse in the left lower
quadrant. There were no abnormalities found on physical examination of the liver, kidneys, and
spleen.
3.7.2 Second Consultation-November 2007
The second consultation took place four weeks after the first consultation. The participant had not noticed a change in her symptoms and no new or additional symptoms had appeared.
Vital Signs and Observations
• The participant seemed particularly restless, anxious, and irritable
• The vital signs recorded were:
o Pulse: 80 beats per minute
o Respiratory rate: 18 breaths per minute
o Temperature: 36.7 ac o Blood Pressure: 100/60, right arm, sitting up
Motivation for the Remedy Selection
The following aspects of the selected remedy, Nux vomica indicated its use in this case: diarrhoea aggravated by menses; alternation of diarrhoea and constipation; burning pain in the epigastric region; flatus and diarrhoea with spasmodic colic worsened by eating and drinking; loud rumbling in abdomen; 'quiets anxiety with sedative effects of tobacco'; late nights with not enough sleep; hypersensitivity of the nervous system, 'everything makes too strong an impression' -odours; becomes cold easily; fastidious; headaches worse for tobacco and better for resting (Murphy, 1993; Vermeulen, 2001).
Prescription
Nux vomica 30CH, two powders daily for two weeks, then one powder daily for the next two weeks.
3.7.3 Third Consultation-December 2007
The third consultation took place four weeks after the second consultation. The participant had not noticed an improvement in her symptoms. She complained of diarrhoea, which consisted of undigested food associated with spasmodic, cramping pains. She was feeling restless and anxious, and worried about her future, finances and her family situation. Her moods were changeable, alternating between good and bad. She felt disappointed at the end of her studies at not having been able to commit herself more. She drank coffee in order to keep herself awake and functioning. Her energy levels were extremely low and she felt "depressed".
Vital Signs and Observations
• The participant appeared hurried, troubled and tired
61
"
"
-
--
• The vital signs recorded were:
o Pulse: 76 beats per minute
o Respiratory rate: 17 breaths per minute
o Temperature: 36.7 oc o Blood Pressure: 100/60, right arm, sitting up
Motivation for the Remedy Selection
Ignatia amara was chosen for the following reasons: anxiety and hurried temperament; alternation of moods; headaches worse for tobacco and strong odours; rumbling in abdomen; colicky abdominal pains; diarrhoea from emotional upsets (Murphy, 1993; Vermuelen, 2001). Nux Vomica seemed to be the most indicated remedy but did not elicit any response from the participant's vital force. The association between Nux vomica and Ignatia amara was also considered when the remedy was chosen.
Prescription
Ignatia amara 30CH, one powder daily for four weeks.
3.7.4 Fourth Consultation-January 2008
The final consultation took place four weeks after the third consultation. The participant was feeling "a lot better". She felt more motivated to do her work and even started exercising a week prior to the consultation. She no longer felt depressed and anxious about her future. Even though her stressors remained the same, she felt she was able to cope more easily with them. Since she started taking Ignatia amara she no longer had abdominal cramps or bloating. The diarrhoea had improved, but had returned after copious alcohol consumption on a night out and with her attempt at ceasing smoking with nicotine patches. She revealed that she had been experiencing anxiety attacks prior to her treatment, which had been minimised considerably. The vomiting episodes brought on by stress had stopped.
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 74 beats per minute
o Respiratory rate: 17 breaths per minute
o Temperature: 36.5 oc o Blood Pressure: 100/60, right arm, sitting up
62
---
Case Seven --A.bdorrnnal Pam ---~~---,--"'------~--·---· ·-----------··
----Empty fe..,.t1ng 'n Atdomtnal area
Abdom1nal RLJmbhr.g
--Abdominal 8toat1ng
-'Nind
.........-Decreased passagt' of St•)•:d
~ lncrease•1 passage of Stool
--lnc•)mpleta passage of St•)<:ol
--Har•1 Stool
0
Consultation 1 ConsuHation 2 ConsuHation 3 Consultation 4 Stramtng w1th passage of Stcol
Figure 3-19: Gastrointestinal Symptom Ratings for Participant Seven.
Case Seven ---------·--~--------·--·------·--·---·-··---
~ -How are yeo feeilng on Gel'erai?
Have felt depre=d ao;nng the past tv-10 -,.,-eeks-:>
1----e:o-----------~~-------T--1---.,.f<----..:1 ------Have 7'0u felt ar:x1ous or nervous durmg the past 1\~o "'-eeks7
~How .lre ycur el'ergy •evels?
-.-lave y-ou fe~ healthy enough to do the th1ngs you '-'¥ant j had to?
--;,ave you felt wcmed or up :;et cunng 1----------"'*:._--:ll.----.,;::..-/-1---------1 the past 1\~-o weeks~
Consultaton 2. Cor:Sulta:;on.!
--How Jften :1ave j'OU ~~~ hacpy L1unng the pJst \'lho weeks?
Figure 3-20: General Well-Being Ratings for Participant Seven.
63
,,
",,
--,,...
-,,..
Case Seven 35
30
25
20 s:: 5 (/)
:5
10
5
0
Consultation I Consultation 1 Consultation 3 Consultatlon4
Figure 3-21: Sum of Physical Symptoms and General Well-being for Participant Seven. (Well-being should increase and symptoms should decrease)
3. 7.5 Overview and Discussion of Case Seven
The participant received two prescriptions. The initial prescription was Nux vomica. The participant experienced an aggravation of physical symptoms between the second and third consultations (Figure 3-19), with a concurrent decrease in general well-being during this period (Figure 3-20). It was decided that the remedy was not appropriate, and Ignatia amara was prescribed at the third consultation. Figure 3-19 and Figure 3-20 show an improvement in physical symptoms and general well-being from the third consultation to the fourth consultation, respectively. This indicates that Ignatia amara elicited a favourable therapeutic result.
The participant's diet was varied, but excluded any animal products. The participant occasionally binged on alcohol, which aggravated her symptoms. Her stress levels were continuously high, which also contributed to the severity of her symptoms. Stress management and limiting alcohol may sustainably improve the participant's IBS symptoms over a prolonged period of time.
64
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•
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3.8 CASE EIGHT
3.8.1 First Consultation-December 2007
Summary of the Presenting Case
• White female
• Year of birth: 1983
• Single
• No children
• Occupation: Fleet Administration Controller
A 24 year old female presented with IBS, which started one year ago.
The participant complained of bloating after every meal with flatulence and urgency for stool. She occasionally experienced cramping pains and discomfort in the epigastric and rumbling region. Her bowel movements alternated between diarrhoea and constipation. She sometimes experienced difficult evacuation of stools.
Generally, the foods that aggravated her symptoms were bread, pasta, and all "starchy" foods. She felt cold easily. Her posterior cervical glands tended to swell, especially on the right side. She complained of occasional night time cramps in her feet and calves.
The participant's moods were changeable. She enjoyed company and consolation. She disliked being alone. She described herself as motivated and ambitious.
Medical History
No medical history of significance
Medicine
• Mercilon® oral contraceptive pill
Vital Signs and Observations
• The participant was friendly and talkative.
• The vital signs recorded were:
o Pulse: 65 beats per minute
o Respiratory rate: 16 breaths per minute
o Temperature: 36.5 oc o Blood Pressure: 100/70, right arm, sitting up
• On examination of the abdomen, there was tenderness in the epigastric region on deep palpation.
The liver was not enlarged and non-tender. The kidneys and spleen were normal.
65
, ...
,.,.
...
-
-------• -• --
3.8.2 Second Consultation-January 2008
The second consultation took place four weeks after the first consultation. The participant reported that there had been no changes in her symptoms since the first consultation.
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 68 beats per minute
o Respiratory rate: 17 breaths per minute
o Temperature: 36.5 oc o Blood Pressure: 100/70, right arm, sitting up
Motivation for the Remedy Selection
The following aspects of this case were taken into consideration when choosing the remedy: Starchy food aggravates symptoms; flatulence aggravated by food; bread aggravates; rumbling after eating; better for consolation; moods changeable; fear of being alone; feels the cold easily; swelling of the glands; cramping in the lower limbs at night (Murphy, 1993; Vermuelen, 2001).
Prescription
Pulsatilla pratensis 30CH, two powders daily for two weeks, then one powder daily for the next two weeks .
3.8.3 Third Consultation-February 2008
The third consultation took place four weeks after the second consultation. The participant had tried to minimise the 'starch' in her diet. She had also been exercising regularly. She generally felt better but was still suffering from flatulence. She had experienced an episode of diarrhoea, with a sudden urge for stool, and an "aching body" during a period of two days when she was "coming down with flu".
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 62 beats per minute
o Respiratory rate: 15 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 100/60, right arm, sitting up
66
.. •
"" ... ••
"'"'
....
------• -• -,.,,
Motivation for Remedy Selection
The participant had experienced an improvement in her symptoms. It is unclear what effect the remedy had as she had changed her diet and included exercise in her routine. The positive outcome justified the repetition of the remedy.
Prescription
Pulsatilla pratensis 30CH, one powder daily for two weeks then wait and watch for two weeks.
3.8.4 Fourth Consultation-March 2008
The fourth consultation took place four weeks after the third consultation. The participant had noticed a general improvement in her bowel symptoms, most prominently her bowel movements had "normalised". Her stools were easy to pass and she had less constipation. Her cramping abdominal pains had gone. Her abdominal bloating and rumbling had been reduced. She was however feeling 'stressed' because she was studying and working .
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 65 beats per minute
o Respiratory rate: 16 breaths per minute
o Temperature: 36.5 oc o Blood Pressure: 100/60, right arm, sitting up
67
3 --AbrJorntnal Pam
--41-Empty feeltng ;n At .. JomHlal area
Abdominal F;·umblmg
----···· Abd.;,m 1 nal 8Joat1 ng
-Decreased passage of Stool
1 --Incomplete passage of Stool
--Har.j StO•)I
0 Loose St•)•)l
Consultation 1 Consultation 2 Consultation 3 Consultation 4 Strammg with pas sag<? of Stool
Figure 3-22: Gastrointestinal Symptom Ratings for Participant Eight.
Case Eight 5 -···--- -·-- ... ------~-- --~ ---~--- -··"·
,/ -How Jre you feeling m Ger:erai?
// -it-H :.ve you been Jl or ~rw.-e!l 1n the pas: 4
~/~ tvvo '-,..·:eeks:
Have felt d-=pre;:sed dunng the past ~.~o weeks~
Cl ·-w··-H:Neyou felt 3f!XItlUS or neNous dur;ng t: 3 ·= the past t.Nu weeks?
RJ ... ... -How Jre your er.ergy !eveisr t: ·a Q. 2 I -Have you felt healthy enot.'\)h to do the 1,()
th1ngs you Nant r had to? ....
-Have you felt wcrned or U!= ;et dunng
I the pa'St !'No ·,.,;eeks':'
--How often have you f~lt happy dunng - :he past tl.vo we~h s7·
f)
Co-rsult :stton 1 Ccnsul! 3tton 2 Consult :;tton :. Cor.sulta!lon"
- Figure 3-23: General Well-Being Ratings for Participant Eight.
-68 -
• -
~:·f
;.jl.
·-
-------• -
Case Eight ,,, -..'-..'
30
11:: -.J
20 E :::l (I)
15
10
5
0
Consultation 1 Consultat1on 2 Cocsultalion 3 Consultation 4
Figure 3-24: Sum of Physical Symptoms and General Well-being for Participant Eight. (Well-being should increase and symptoms should decrease)
3.8.5 Overview and Discussion of Case Eight
The participant showed favourable changes to Pulsatilla pratensis. This is illustrated in Figure 3-24, which shows a decrease in symptom severity corresponding to a decrease in general well-being during a particularly stressful time. This may be due to the limitation of 'starchy' foods in her diet that had previously aggravated her. The participant's overall well-being ratings were high (Figure 3-23).
A large portion of the participant's diet included convenience foods, with only a small quantity of fresh fruit and vegetables included. Despite the realisation that certain foods aggravated her symptoms, the participant listed many of these in her food diary as food she consumed regularly before the third consultation. By limiting these foods in conjunction with homoeopathic treatment, the participant experienced an improvement in her IBS symptoms.
69
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3.9 CASE NINE
3.9.1 First Consultation-December 2007
Summary of the Presenting Case
• Coloured female
• Year of birth: 1972
• Single
• One pregnancy, one child
• Occupation: Tourism Development Coordinator
• Resides in Knysna
A 35 year old female presented with IBS, from which she had suffered for four years.
She complained of terrible "wringing" abdominal pain in her epigastric area associated with bloating. She had a burning sensation retrosternally after heavy meals. The abdominal symptoms were worse at night and better for passing stool and pressure. Her stool alternated between hard, yellow stool which was difficult to evacuate and soft, loose, excoriating stool which looked like it contained fibre. These symptoms were aggravated by spicy and farinaceous foods.
Generally, the participant felt hot easily. She woke up every morning at 4.30am and could not go back to sleep. She had "clairvoyant dreams". She craved bread and pastries and was averse to bananas and soup (due to its consistency). She menstruated every two weeks and felt particularly emotionally insecure during this time. She suffered from allergic rhinitis which was worse at night.
The participant was in a long term relationship with an alcoholic. This distressed her as they had been together for more than ten years and had a daughter together. She had a great desire to travel and escape her situation. She dealt with her emotions alone, by writing and painting. She felt selfconscious about her weight but loved food and cooking.
Medical History
• Tympanic membrane surgery
• Allergic to metaclopomide
• Pre-eclampsia with full term pregnancy and healthy baby, age 26
Medication
• Lactovita® supplement
• Buscopan® antispasmodic
• lnteflora® probiotic
70
'111'111!
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 67 beats per minute
o Respiratory rate: 16 breaths per minute o Temperature: 36.9 ac o Blood Pressure: 110/80, right arm, sitting up
• There was pain on deep palpation in the left hypochondriac region on abdominal examination.
The liver was not enlarged and non-tender. The spleen and kidneys were normal.
3.9.2 Second Consultation-January 2008
The participant was feeling less stressed because she had finally moved out of her boyfriend's apartment. Her symptoms had fluctuated during this period, but had been worse in the past week after a colleague had passed away suddenly.
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 72 beats per minute
o Respiratory rate: 16 breaths per minute o Temperature: 36.5 ac o Blood Pressure: 120/80, right arm, sitting up
Motivation for the Remedy Selection
The following aspects of the chosen remedy were considered: clairvoyant dreams; desire to travel; creative; loquacious; great hunger; flatulent and distended abdomen; difficult evacuation of stool; yellow stool; spicy food aggravates; alternating constipation and diarrhoea; burning pain during stool; menses every fourteen days; ailments due to strong emotions (Murphy, 1993; Vermuelen, 2001).
Prescription
Phosphorus 30CH, one powder daily for four weeks.
.... 3.9.3 Third Consultation-February 2008
-• -• -• ---
The third consultation took place four weeks after the second consultation. She was feeling particularly stressed at the time of the consultation due to her unhappiness at work and issues related to her break-up with her long-term boyfriend. She had had "stomach flu" and had been feeling miserable, emotionally and physically for the past few days. She had however noticed an improvement in most of her abdominal symptoms (bloating, flatulence and abdominal pain) and, in general felt better able to cope with the stresses she encountered .
71
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--
----•
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 76 beats per minute
o Respiratory rate: 18 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 125/80, right arm, sitting up
Motivation for the Remedy Selection
The participant had noticed a general improvement in her symptoms and in how she was feeling. Despite current circumstantial stresses. Based on this positive response, the decision was made to continue the prescription of Pho!>phorus.
Prescription
Pho!>phorus 30CH, one powder daily for four weeks
3.9.4 Fourth Consultation-March 2008
The final consultation took place four weeks after the third consultation. The participant had noticed a general improvement in her abdominal symptoms but recognised a pattern of remittance on weekends. This she felt was due to her "food binges" and diet rich in fatty foods, which she ate on the weekends. As a result, she experienced bouts of diarrhoea and cramping abdominal pains. Emotionally she felt "indifferent" and often had a "knot in the stomach". She felt frustrated with her life due to the limitations of her work. She had ended her long-term relationship with her abusive partner, but "does not think about it" as it was too emotionally upsetting for her.
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 78 beats per minute
o Respiratory rate: 19 breaths per minute
o Temperature: 36.5 oc o Blood Pressure: 110/80, right arm, sitting up
72
!'ll''!t
----
Case Nine 3 ---------1#---·----·,
! --- Em~CIY !~ling :n AMorn:nal area
Abdominal Rumbling
--Abdominal Sloatmg
-Decreased passage of St•)OI
---Increased pas·;age of Stool
--Incomplete passage of Stool
--Hard Stool
Loose St-Jol
0
Consultation I ConsuHation 2 ConsuHation 3 Consultation 4 Stra1n1ng •Nith passage of Stool
Figure 3-25: Gastrointestinal Symptom Ratings for Participant Nine.
5
4
01 c: 3 'i ... E ·s 9- 2
II')
\)
Case Nine ------------------------ ----------------- -------- --------------------------- '---"1.------------------,
-How are you feeilng 111 General?
-t1-- H 3Ye you been Jil or unll';eil 1n the past +----------- ----------------<-----11 two weeks?
Have felt depressed dunng the past ~NO weeks?
t----e.:::-------A:--------------;f---::P..----11--· H.3Ve you felt arc<~ous or nervous dunng the past two weeks?
; --How .are yo1;r er.ergy :evel-s 1
, __._Have you felt heJithy enough to do the things you want i had to 7
' : -:-Have you ielt vvcmed or upset dunng t----""::;._--------------''11''-------------'·1 the past two weeks7
Consultatton 1 Cor.sult3tJon 2 Consult :lt1on 3 C or:s ultat1 on 4
! --How often have you felt h.1;Jpy dunng tl1e p3st !lt10 ~hs?
Figure 3-26: General Well-Being Ratings for Participant Nine.
73
·--....
--
Case Nine
Consultation l ConsultatiOn 2 Consu1tat1on 3 Cons ultatton 4
Figure 3-27: Sum of Physical Symptoms and General Well-being for Participant Nine. (Well-being should increase and symptoms should decrease)
3.9.5 Overview and Discussion of Case Nine
The participant showed an initial worsening of symptoms in response to Phosphorus. The participant had noticed an improvement in individual abdominal symptoms after the initial administration of Phosphorus, which subsequently worsened again after. This affected her general well-being, most notably (as illustrated in Figure 3-27) the third consultation. The fourth consultation ratings show an improvement in general well-being with an increase in symptoms. The participant's food diary revealed a diet high in processed and fried foods. As the participant acknowledged, her periodic physical aggravations may have been caused by a poor diet and habit of binge eating. Another factor to consider when analysing this case is that the participant had experienced many emotionally intense events during the study period. These aspects present themselves as very important precipitants in the case of IBS, remaining the greatest obstacles to cure. The chosen similimum remedy therefore had limited effect. The importance of a change in diet (a reduction of processed and fried foods), addressing the participant's binge eating, and education on stress reduction techniques may provide the participant with prolonged relief from the symptoms of IBS .
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3.10 CASE TEN
3.10.1 First Consultation-February 2008
Summary of the Presenting Case
• White female
• Year of birth: 1980
• Single
• No children
• Occupation: Student
• Resides in Johannesburg
A 27 year old female presented with IBS, from which she had suffered since approximately ten years.
She complained of stabbing abdominal pains in the epigastric and periumbilical regions which were worsened by anxiety and alleviated by warmth. Her stools were primarily loose, but also hard and difficult to evacuate during periods of stress. She also suffered from bleeding haemorrhoids associated with stress. She experienced flatulence and bloating which were both worse during her menses and stress.
Generally, the participant felt hot. She loved the ocean because of the space (so she did not feel suffocated). She dreamt of younger men and felt guilty as a result. She often had a 'nervous', empty sensation in her stomach which decreased her appetite. She craved olives and chocolate.
Emotionally, she felt drained and depressed. Her father had been in a coma in hospital for five months, with an uncertain outcome. She did not like to talk about her problems but said her religion was what was helping her through this major crisis in her life. She often woke up at night crying. She felt frigid towards her boyfriend and kept her worries to herself because she did not want to burden him. The participant had a difficult time trusting people. She described herself as trustworthy and dependable with a good perception of people.
Medical History
• Appendectomy, age 19
• Thyroid lobectomy of right lobe, age 25
Medication
• Eltroxin® 0, lmg daily
Vital Signs and Observations
• The patient appeared reserved and both physically and mentally exhausted. She disliked talking
about herself and felt embarrassed at having to relate personal details .
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• -
• The vital signs recorded were: o Pulse: 80 beats per minute
o Respiratory rate: 18 breaths per minute o Temperature: 36.7 oc o Blood Pressure: 90/60, right arm, sitting up
• The abdomen was tender on deep palpation. Normal bowel sounds were heard in the right lower
quadrant. The liver was non-tender and not enlarged. The kidneys and spleen were not enlarged.
3.10.2 Second Consultation-March 2008
The second consultation took place four weeks after the first consultation. The participant had not noticed a difference in any of her symptoms. She had married and was feeling more "stable" in her life.
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 76 beats per minute
o Respiratory rate: 17 breaths per minute
o Temperature: 36.5 oc o Blood Pressure: 100/60, right arm, sitting up
Motivation for the Remedy Selection
The following attributes were taken into consideration: suspicious and mistrustful of people; reserved demeanor; bleeding haemorrhoids; 'knife-like' abdominal pain with anxiety, ameliorated by warmth; anxiety in the stomach; constipation during menses; swelling of thyroid gland (Murphy, 1993; Vermuelen, 2001).
Prescription
Sepia 30CH, one powder daily for four weeks.
3.10.3 Third Consultation-April 2008
The third consultation took place four weeks after the second consultation. The participant had not experienced abdominal cramps or flatulence since she had been taking the remedy. Her bowel movements had changed from loose to difficult stools during menstruation. The passage of stool was painful, like "passing razor wire" and accompanied by bleeding from haemorrhoids. She complained about her "skin breakouts'· which were located on her cheeks and worsened by stress. The pustules were painful to touch and looked "purple". The participant's headaches had worsened. She was experiencing headaches daily, towards afternoon. The headaches were worsened by exhaustion and intense emotions. Emotionally, the participant felt "drained" and "tired of life". When she felt very exhausted from her daily demands, the participant had occasional thoughts of suicide. She thought about a car accident and felt that it would allow her to "rest".
76
"'
''"'
Vital Signs and Observations
• The vital signs recorded were:
o Pulse: 68 beats per minute
o Respiratory rate: 16 breaths per minute o Temperature: 36.5 oc o Blood Pressure: 112/78, right arm, sitting up
Prescription
Ignatia amara 30CH, two powders daily for two weeks, then one powder daily for the following two weeks.
Motivation for the Remedy Selection
Inappropriate emotional responses; tired of life; stabbing headaches brought on by emotions; constipation alternating with diarrhoea; skin eruptions; effects of grief and worry; melancholic; stitching pain in rectum and anus on passing stools; 'pressure as of a sharp instrument from within outward' (Murphy, 1993; Vermuelen, 2001).
3.10.4 Fourth Consultation-May 2008
The fourth consultation took place four weeks after the third consultation. The participant felt less tired on waking, and felt she had more "strength". She experienced less frequent headaches, which occurred only twice weekly now. Her abdominal cramps and bloating had disappeared. The participant still experienced constipation, which had worsened prior to and during her menstruation.
Vital Signs and Observations
- • The vital signs recorded were: o Pulse: 72 beats per minute
o Respiratory rate: 18 breaths per minute
o Temperature: 36.5 oc o Blood Pressure: 120/75, right arm, sitting up
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.. --.. -
CHAPTER FOUR RESULTS
4.1 INTRODUCTION
The Gastrointestinal Symptom Rating Questionnaire (Appendix D) and General Well-Being
Questionnaire (Appendix E) were used to evaluate the participants' subjective abdominal symptoms
and well-being respectively, at each of the four consultations over the period of twelve weeks. Both
questionnaires used numerical rating relating to symptom severity. The Gastrointestinal Symptom
Rating Questionnaire made use of eleven abdominal symptoms, which were rated between 0 and 3
(where 0 indicated no symptom and 3 indicated constant/severe symptoms). The General Well
Being Questionnaire made use of eight psychological symptoms, which were rated between 0 and 5
(where 0 indicated the worst sense of well-being and 5 indicated the best sense of well-being). The
questionnaires assisted the researcher in assessing whether there were any changes in physical as
well as psychological symptoms. These ratings were indicative of the success (or the lack thereof) of
treatment.
,., The Daily Symptom Grading Sheet (Appendix G) was used as a subjective measurement of the
1n participants' abdominal symptoms on a daily basis. Five symptoms were rated between 1 and 5
,.. (where 1 indicated the worst symptoms and 5 indicated no symptoms). In conjunction with the Daily
10 Food Diary (Appendix F), the Daily Symptom Grading Sheet was used by the researcher to interpret
the impact diet and stress had on the abdominal symptoms.
The data collected was interpreted using graphical representations. The results were graphically
interpreted as a bar chart for each case on the sum of the Gastrointestinal Symptom Rating
Questionnaire & General Well-Being Questionnaire.
The Friedman Test was used to analyse statistical variance and significance. Both the statistical and
...,. clinical significance of the results have been considered.
--• -- 80 ---
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1 11111
'lit
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---.. • -• -• --
4.2 STATISTICS
Hypotheses
Null hypothesis: The homoeopathic similimum remedy is ineffective in alleviating the symptoms of
IBS.
Hypothesis: The homoeopathic similimum remedy is effective in alleviating the symptoms of IBS.
The null hypothesis represents a hypothesis that must be proven false in order to support an
alternative hypothesis. The presumption is made that it is true unless statistical evidence proves
otherwise (Weinsstein, 2004).
Probability Values (P Values) and Statistical Significance
Statistical significance is represented by the probability value (p- value which is < 0.05). Using this
value as a guideline, the null hypothesis can be tested for statistical significance or lack thereof
(Weinsstein, 2004). In this study the Friedman Test was used in order to ascertain the p- values for
the five abdominal symptoms which were considered by the Daily Symptom Grading Sheets.
Clinical vs. Statistical Significance
Statistical significance is the likelihood that the difference found between groups could have
occurred by chance alone. This is based on calculations from which the p- value can be derived.
Clinical significance is subjective and involves personal judgement (Medical University of South
Carolina, 2004).
Friedman Test
The Friedman test evaluates three or more sets of data to determine whether there are any variations
between them. This allows for the calculation of the p-value. 'Rank/s' refers to 'a measure that
assigns observations to an order from first to last, highest to lowest , or most to least'(Miller, 1995).
81
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Degrees of freedom (d.f) 'refers to the extent to which scores can vary once certain restrictions have
been imposed on them' (Hicks, 1990).
4.3 FRIEDMAN TEST RESULTS
4.3.1 BLOATING
TABLE 4-1: Descriptive Statistics
N Mean Standard Minimum Maximum Percentiles
Deviation (25th) (50th) (75th)
Bloating 10 2.8750 0.59767 2.04 3.96 2.4286 2.7679 3.3125
Average
Month 1
Bloating 10 3.2143 0.80952 1.86 4.64 2.6250 3.2321 3.7768
Average
Month 2
Bloating 10 3.2929 1.01920 1.61 4.50 2.2143 3.5536 4.2411
Average
Month 3
TABLE 4-2: Ranks
Mean Rank
Average (Month 1) 1.85
Average (Month 2) 1.95
Average (Month 3) 2.20
TABLE 4-3: Test Statistics
N 10
Chi-square 0.667
Of 2
Asymp. Sig 0.717
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Interpretation of results for Bloating
Notice the improvement in both mean (2.88, 3.2, 3.3) and mean rank (1.85, 1.95, 2.2); however the
improvement is not statistically significant (p = 0. 717 which is > 0 .05).
4.3.2 ABDOMINAL PAIN
TABLE 4-4: Descriptive Statistics
N Mean Standard Minimum Maximum Percentiles
Deviation (25th) (50th) (75th)
Abd.pain 10 3.000 0.99360 1.54 5.00 2.3750 2.9286 3.4911
Average
Month 1
Abd.pain 10 3.1893 0.93890 1.82 4.21 2.000 3.5714 3.9554
Average
Month 2
Abd.pain 10 3.5357 1.00776 1.68 4.61 2.6518 3.8929 4.4375
Average
Month 3
TABLE 4-5: Ranks
Mean Rank
Average (Month 1) 1.60
Average (Month 2) 2.00
Average (Month 3) 2.40
TABLE 4-6: Test Statistics
N 10
Chi-square 3.200
Df 2
Asymp. Sig 0.202
83
....
----• -----
Interpretation of results for Abdominal Pain
Notice the improvement in both mean (3.0, 3.1, 3.5) and mean rank (1.6, 2.0, 2.4); however the
improvement is not statistically significant (p = 0.202 which is > 0 .05).
4.3.3 FLATULENCE
TABLE 4-7: Descriptive Statistics
N Mean Standard Minimum Maximum Percentiles
Deviation (25th) (50th) (75th)
Flatulence 10 3.1321 0.5585 2.29 4.36 2.7946 3.1607 3.3214
Average
Month l
Flatulence 10 3.5321 0.50436 2.68 4.11 3.1429 3.5536 3.9911
Average
Month 2
Flatulence 10 3.8393 0.67243 3.00 5.00 3.1071 4.0179 4.2411
Average
Month 3
TABLE 4-8: Rank
Mean Rank
Average (Month 1) 1.50
Average (Month 2) 2.00
Average (Month 3) 2.50
TABLE 4-9: Test Statistics
N 10
Chi-square 5.000
Df 2
Asymp. Sig 0.082
84
-
-------
Interpretation of results for Flatulence
Notice the improvement in both mean (3.1, 3.5, 3.8) and mean rank (1.5, 2.00, 2.5). However the
improvement is not statistically significant (p = 0.082 which is > 0 .05).
4.3.4 DIARRHOEA
TABLE 4-10: Descriptive Statistics
N Mean Standard Minimum Maximum Percentiles
Deviation (25th) (50th) (75th)
Diarrhoea 10 3.7893 0.94603 2.57 5.00 3.0804 3.3929 4.8393
Average
Month 1
Diarrhoea 10 3.9107 0.86950 2.57 5.00 3.0982 3.9464 4.7946
Average
Month 2
Diarrhoea 10 4.0071 0.68570 2.61 4.82 3.6518 3.9821 4.6071
Average
Month 3
TABLE 4-11: Rank
Mean Rank
Average (Month 1) 2.00
Average (Month 2) 1.70
Average (Month 3) 2.30
TABLE 4-12: Test Statistics
N 10
Chi-square 1.895
Df 2
Asymp. Sig ().388
85
• --
----------
Interpretation of results for Diarrhoea
The results of this test suggest that there is no significant difference in scores across the three time
periods. This is indicated by the significance level of p = 0.388 ( < 0.05)
4.3.5 CONSTIPATION
TABLE 4-13: Descriptive Statistics
N Mean Standard Minimum Maximum Percentiles
Deviation (25th) (50th) (75th)
Constipation 10 3.5000 1.02145 1.79 5.00 2.7857 3.7857 4.1786
Average
Month 1
Constipation 10 3.5786 0.87754 1.96 5.00 2.9911 3.6250 4.2054
Average
Month 2
Constipation 10 3.4429 0.98129 1.96 5.00 2.6696 3.4821 4.2321
Average
Month 3
TABLE 4-14: Ranks
Mean Rank
Average (Month 1) 1.85
Average (Month 2) 2.05
Average (Month 3) 2.10
TABLE 4-15: Test Statistics
N 10
Chi-square 0.400
Df 2
Asymp. Sig 0.819
86
--• --
-------• -
Interpretation of results for Constipation
The results of this test suggest that there is no significant difference in scores across the three time
periods. This is indicated by the significance level of p =0 .819 (>0.05)
4.3.6 Conclusion of Friedman Test
The Friedman Test shows that the results were not statistically significant for the five symptoms
analysed (p-value NOT < (l.05). The null hypothesis can therefore not be rejected.
However, when comparing the mean ranks for all five symptoms, it appears that there was a steady
increase, which indicates an overall favourable response to treatment even though it cannot be
considered statistically significant.
4.3.7 Clinical Conclusion
The trend in the mean rank<> of the Friedman test reflected the improvement in bloating, abdominal
pain, flatulence, and constipation, which is clinically relevant, some symptoms more than others.
The General Well-Being Questionnaires for all participants showed a general trend of improvement
over the treatment period.
87
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
5.1 DISCUSSION AND CONCLUSION
• All ten participants completed this study. This is of importance as it reflects the enthusiasm of these
individuals to comply with the treatment regimes. Since compliance was 100%, it can be assumed
that all participants experienced a therapeutic benefit. This is best illustrated by comparing the sum
of the physical symptoms and general well-being at the first consultation and last consultation for
- each participant. All ten participants showed a clinical improvement when comparing the physical
ratings at the first and the fourth consultations. Eight out of ten participants showed an improvement
- in general well-being when comparing the first and the fourth consultations. At the time of her
- participation in this study, participant three (case three) had examinations and was planning to travel
• alone for the first time. The decrease in her general well-being may be attributable to this.
• Participant eight (case eight) did not follow the trend of an improvement in well-being, though her
• IBS symptoms decreased. The decrease in her general well-being may have been stress-related. It is
• assumed that all questionnaires were completed with honesty .
• - Certain factors must be considered when analysing the results of this study. The symptoms of IBS
- are precipitated by certain influences such as anxiety related to stress and diet. These are variables
that were not controllable in this study and may have had an impact on the results. In the absence of
"'" any statistically significant results, it is assumed that the limitation of this study is that it excluded
any other lifestyle modifications. It can therefore be concluded that the similimum method has
- limited therapeutic effects for IBS when it is used in isolation.
--• -•
-- 88 --
'I
5.2 RECOMMENDATIONS
5.2.1 Further Research
Based on the results of this study, it is recommended that:
• A study on IBS should be undertaken using two groups; a group whose diet is altered in
conjunction with homoeopathic similimum treatment, and a group who receives only
homoeopathic similimum treatment.
• Participants must be monitored over a longer period of time in order to acquire more
comprehensive results for statistical analysis.
• A larger sample group should be used in order to obtain more statistically significant results
- 5.2.2 Benefits and Limitations of the Study
-• ---
---• -• -• --
Homoeopathic treatment of IBS in conjunction with lifestyle and dietary management may provide a
cost effective, non-toxic, and non-invasive alternative for people suffering from IBS.
Anxiety related to stress and diet were identified as limitations in this study. It is difficult to isolate
amelioration and aggravation of symptoms from these influences.
89
, ..
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97
' . ,. '~
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APPENDIX A
ROME III CRITERIA FOR IBS*
Do you suffer from:
Abdominal pain or discomfort that is recurrent and associated with two or more of the following:
• An improvement with the passage of stool
• Change of frequency of stool since onset
• Change of appearance of stool since onset
Three months of the past six months, I have suffered from the above YES D
Study Inclusion Criteria:
• Female Gender • Age (20-35) Date of Birth-----• Diagnosed with IBS in (year) ____ _
Study Exclusion Criteria:
• Inflammatory bowel disease (Crohn's and ulcerative colitis) • Bowel Cancer • Chronic diseases • Pregnancy
Signature: ----------- Date:-----------
Name:--------------------------
* Chang, L. (2006). From Rome to Los Angeles-The Rome III Criteria for the functional
gastrointestinal disorders.
98
,,
,.,
, ..
----• ----
APPENDIXB
PATIENT INFORMATION AND CONSENT FORM
Dear Volunteer,
My name is Geraldine Hachler, and I am a 5th year homoeopathy student and intern at the
Homoeopathy Health Center at the University of Johannesburg. I am undertaking this study in
completion of my M.Tech Homoeopathy qualification.
You are invited to participate in this research study. IBS is a functional disorder of the
gastrointestinal tract characterised by symptoms such as abdominal bloating, pain in the abdominal
area and alternating bowel habits. At present, conventional treatment offers drugs to reduce the
predominant symptoms, with the risk of experiencing other side-effects. Your participation in this
study will contribute to furthering the knowledge and improving the treatment of IBS.
The intention of this study is to establish whether homoeopathic treatment benefits sufferers of IBS.
The aim of this research is to evaluate whether homoeopathic treatment assists in relieving IBS over
a period of 12 weeks. You are requested to participate in a minimum of four consultations with an
initial 4 week period between the first and second consultation when you will be asked to monitor
your symptoms without treatment. All consultations will be held at the University of Johannesburg's
Homoeopathy Health Center, Doornfontein. Your treatment is free of charge. All consultations are
supervised by a qualified clinician.
Your first consultation will consist of a homoeopathic interview to establish a symptom picture. It
will also include a physical examination consisting of an abdominal examination and vital signs
such as blood pressure, temperature, breathing rate, and pulse. You are requested to complete a
graded symptom analysis questionnaire as well as a general well-being questionnaire at each
consultation and keep a record of your daily food intake and symptoms using a daily rating sheet.
There will be a minimum of three follow-up consultations where you will be asked about your
symptoms and physically examined if necessary. You will receive homoeopathic treatment in the
form of powders to be taken twice daily from the second consultation onwards.You have chosen to
99
-----
participate in this study on a voluntary basis, and you are therefore free to withdraw from the study
and decline treatment at any time. If you do not meet the criteria for this study, you will be referred
appropriately.
A signed copy of this form will be given to you. Information received will be confidential and you
will remain anonymous. Measures ensuring this include limiting access to your file by keeping it in
a secure storage facility in addition to your name being replaced by a case number.
If there are any questions or problems relating to the study, please contact either the researcher or
supervisor. For the contact details, please refer to the bottom of this form.
Please do not make use of any allopathic, herbal, any other form of drugs during this study. If the
use of other medications apart from the ones prescribed to you during the study is unavoidable, you
are requested to document this and inform the researcher.
I, ___________________ the voluntary participant have been completely
informed about the procedure of this study. I acknowledge that I may at any time withdraw my
participation in this study. I acknowledge that I am free to inquire about the research and ask
questions, which will be answered by the researcher and supervisor to the best of their ability.
Signature: ---------- Date: -----
Contact Details: ----------------
I, the researcher, have given a comprehensive explanation of the intended study procedures and
treatment. I will provide the best explanations that I can with regards to questions posed by the
participants.
Signature: __________ _ Date:
Contact Details:
Researcher: Geraldine Hachler
Supervisor: Dr Kathryn Peck
------
Cell: 083 482 7017
Cell: 082 824 2280
100
-
-• -• -....
-
---• -.. 11!111
• -
APPENDIXC
HOMOEOPATHIC INTERVIEW FORM AND PHYSICAL EXAMINATION
Date:
Identifying Data:
Patient Case Number:---------------------Name: _____________________________ _
D.O.BandAge: ______________________________________ ___
Gender: --------------------------------
Race (for statistical purposes): -------------------
Occupation: -------------------------------
Home Address: -------------------------
Presenting Complaint:
101
General Symptoms
Vital Tone:
Vital Temperature:
Environment:
Perspiration:
Sleep: --•
Appetite and Thirst: --- Food Cravings and Aversions: -....
Menses and Sexuality:
''"
Stool and Urine:
....
Side and Position:
·-• -•
102 -
1\1·4
---• --
------• -• -• -
Review of Systems
Head/ Nervous System:
Nose:
Eyes:
Throat:
Respiratory:
Cardiovascular:
Stomach:
Skin:
Musculoskeletal:
Urinary Tract:
Reproductive Tract:
Mental and Emotional
Anxiety /Fear:
Worries/Concerns:
103
--• --
------• -----
Most Distressing Life Event:
Consolation:
Concentration/Memory:
Industrious/Lazy:
Depression:
Habits
Exercise:
Drugs:
Alcohol:
Smoking:
Medical and Surgical History
Vaccinations:
Illnesses and Surgery:
Medication:
Family History:
Physical Examination
Height: ________ _
Weight: ________ _
BMI: ________ _
Blood Pressure:
Temperature:
Respiratory Rate:
Pulse Rate:
104
----
-
---------
C:
A:
J:
C:
0:
L:
D:
Danger Signs:
Rectal Bleeding: ____ _
Weight loss:------
Anaemia: -----------------
Report on finding of examination:
Nocturnal diarrhoea:
Nocturnal abdominal pain:
Fever:
105
•• ,,,.
•Ill
•II.
---.. .. ---
APPENDIXD
GASTROINTESTINAL SYMPTOM RATING QUESTIONNAIRE**
Date: ____ _
Patient Case Number:--------
Mark the symptom rating most applicable to you with an X.
3 2 1 0 Abdominal Pain Constant Fre_guent Occasional No Pain Empty feeling in Constant Frequent Occasional No Empty Abdominal area Feeling Abdominal Constant Frequent Occasional No Rumbling Rumbling Abdominal Constant Frequent Occasional No Bloating Bloating Wind Constant Frequent Occasional No Wind Decreased Every 7 days or Every 5 days Every 3 days 1 times daily OR passage of Stool less Not applicable Increased passage 7 times daily 5 times daily 3 times daily 1 times daily OR of Stool Not Applicable Incomplete Regularly feels Often feel Occasionally feels Complete Stool passage of Stool incomQlete incomplete incomplete Hard Stool Hard stool Hard Stool Somewhat Hard Normal OR Not
alternating with Applicable diarrhoea
Loose Stool Watery Loose Somewhat Loose Normal OR Not Applicable
Straining with Constant Frequent Occasional No Straining R_assage of Stool
** Modified version of the Gastrointestinal Symptom Rating Scale (GSRS) developed by Dimenas,
Svedlund and Wiklund and made available by Mapi Research Institute (2005)
106
I II II II II II f r f I I I I • I APPENDIXE
GENERAL WELL-BEING QUESTIONNAIRE***
Date:-----
Patient Case Number:-----------
The following questionnaire contains questions about how you feel and how you perceive your life situations at this moment. Please mark
the answer that is most applicable to you with an X.
5 4 3 2 1 0
How are you Excellent Very good Good Alternating good Bad Terrible
feeling in and bad
general?
Have you been None of the time Rarely Less than half of Half the time Almost every Every day
ill or unwell in the time day
the past two
weeks?
Have you felt None of the time Now and then Several times Almost every Every day Every day with
depressed during day suicidal thoughts
the past two
weeks?
- -~ ------------
107
I II II I I lilt f .. ' lli ' ~ _._______._ - •-i ii-------i: ,-, - -- -- -
Have you felt Not at all A little Sometimes, Relatively \rery' - Extrernely-
anxious or enough to notice
nervous during
the past two
weeks?
How are your Very energetic Reasonably Energy levels Generally low Very low energy I feel drained
energy levels? energetic vary quite a bit energy
Have you felt Definitely Mostly Limited No, I could only No, I needed No, I needed
healthy enough look after myself someone to help help with
to do the things me with some everything
you want/had to? things
Have you felt Not at all A little Some of the time Quite a bit Very much so Extremely
worried or upset
during the past
two weeks?
How often have All the time Most of the time Often Some of the time A little of the None of the time
you felt happy time
during the past
two weeks? - - - - - - -- - - - -- - -----~-'---
***Modified version of The Institute for Algorithmic Medicine's General Well-Being Schedule (2006-2007)
108
if If I II II II f
APPENDIXF
DAILY FOOD DIAl{Y
Patient Case Number: _________ _
'$ I I i I i
Week No: ____ _
Please be specific when documenting the foods you eat daily and medication you take (if any).
Moo Tues Wed Thurs Fri Breakfast
...
Lunch
Dinner
Snacks
Drinks
Medication
Sat Sun
109
"'"'
...
....
-••
....
----------''"
APPENDIXG
DAILY SYMPTOM GRADING SHEET
Patient Case No: -------------------Week No: -------
Please fill in the number of the rating of symptoms that most applies to you each day.
Rating:
1-worst
2-bad
3-better
4-good
5-excellent/No symptoms
Mon Tues Wed Thurs Fri Sat Sun
Bloating
Abdominal
Pain
Flatulence
Diarrhoea
Constipation
Total Score: -------------Stool Characteristics (blood, frequency, appearance):
110
