CASE TEACHING NOTES
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INTRODUCTION / BACKGROUNDThis case study is designed for use in a variety of classes. I have not taught it yet but will likely teach it this summer. Primarily it is designed for an introductory Anatomy & Physiology class. At our school, the anatomy class is divided into three sections: Anatomy I: Tissues, bones and muscles; Anatomy II: Internal organ anatomy and physiology; and Anatomy III: Nervous system anatomy and physiology. I would most likely introduce it in Anatomy I, because at this stage several of my students are eager to begin working with alternative medicine and not this "Western stuff." I may limit the questions to the blocks of analysis covered only in that trimester and revisit it later when we progress to the other material. Perhaps this case could also be used as a review for the final of a one-semester/one-year Anatomy & Physiology class. The case is also designed for use in a general health class interested in alternative/complementary medicine. In such a class, one could eliminate the anatomy/physiology questions and just proceed to the exploration of various modalities. There are several things I would like the students to pick up from this case. One, that this is a real person with a real problem. Two, that in addition to her spinal problems, Ellen has considerable self-esteem issues and is suffering from depression. By giving the students a true-to-life situation, I feel it will be easier for them to develop clear questions for their exploration. This is a difficult situation for alternative/comp practitioners. Likely more than one approach will be necessary to really help Ellen. What I suspect is that the area that she will be most helped with by using any of these modalities is in the emotional realm. Alternative/complementary medicine can be very empowering for an individual. It tends to foster self-awareness and self-care techniques. Another goal of this case is to introduce first-year students to the critical investigative process. My student population tends to be a little older than most, eager to believe in alt/comp medicine, and also somewhat computer shy and/or resistant. This case would give them an opportunity to proceed into the investigative world of science with something of interest to them. For students outside the world of alternative/complementary education, this case might also serve as an introduction to critical investigative techniques, as well as foster an interest in the alt/comp approaches and serve to broaden their horizons. All the modalities I mentioned are thriving in big cities; many are also budding in smaller towns. The instructor might want to do a preliminary search of their town to determine what might be available to the students in that area. Case Objectives
BLOCKS OF ANALYSISSpinal Anatomy and Spinal CurvatureMy goal would be to introduce this case during the class after we cover spinal vertebrae anatomy. I feel it is important that the students have a fairly good sense of vertebral structure before reading the case. My lectures are mixed with hands-on experiences. I tend to stress vertebral shape and the relationship each vertebrate has to the corresponding ones. I then discuss how the shape of the vertebrae corresponds to forces--gravitational and functional. This leads to a discussion about normal spinal curvature, deviations from normal, and some indication as to the complications of abnormal curvature. I also discuss the ever-changing nature of bone and some of the potential changes in the vertebrae due to the aging process. This is about the time the students start asking questions about chiropractic medicine and sometimes about yoga, Pilates, massage, and the limited role of acupuncture in making structural changes. This case would allow them more time to explore this type of questioning. Idiopathic ScoliosisEllen has what is considered the most common form of scoliosis--idiopathic scoliosis. It is now believed that idiopathic scoliosis is predominantly genetic, and usually more progressive in girls than boys. Idiopathic scoliosis may actually be a secondary effect of a dysfunction of the balancing mechanisms of the brain. Likely, the development of a scoliotic curve is a response to this dysfunction (Keim, 1989). Progression of the curve is often most severe during developmental growth spurts. Similarly, as adults enter their middle years where hormonal and age related changes may effect bone physiology, the curves may once again progress more rapidly. Curves of 45 degrees or more are the most likely to progress. Right thoracic curves (one of the most common) will often result in rib cage structural deformity, often with rib prominence and torso tilt. If the progression of this curve is severe, impairment of cardiopulmonary function may ensue. Secondary curves or compensatory curves are common for individuals with right thoracic curves. Thoracolumbar curves are fairly common and may be either right or left. This type of curve can cause severe distortion between the rib and hip (flank) which may also effect leg length and gait. Major lumbar curves are also common, resulting mostly in severe arthritic pain later in life. Scoliosis screenings of children are common today, though this was not the case when Ellen was a child. If caught early, treatment of scoliosis will often start with exercise therapy, corrective posture techniques, and spinal bracing. Traction is sometimes used, particularly in preparation for spinal surgery. Individuals with curves of 40 degrees or more are often considered candidates for spinal surgery. The purpose of surgery is to fuse several vertebrae in the area of greatest curvature to halt the progression of the curve. Harrington instrumentation and surgical wires are used to support the spine while fusion takes place. Temporary supportive bracing will often follow spinal surgery to enhance the fusion process. If fusion is not complete the individual may experience further curvature and physical complications as they age. This was the case with Ellen. Reference: Keim, H.A., and R.N. Hensinger. 1989. Spinal deformities: scoliosis and kyphosis. Clinical Symposia 41(4). Author's note: This is an excellent resource. I have tried to find an updated version and have not succeeded as of yet. I would appreciate hearing from anyone who knows of an updated version or another source just as good. Immunity and InflammationImmunity and tissue inflammation are covered in the second trimester of anatomy. These topics tend to be a little daunting to students because they have not had much physiology. Before approaching concepts of immunity and tissue inflammation, I make sure I have covered blood cells, blood vessel anatomy, and lymphatic tissue anatomy. I take a very linear, step-by-step approach to covering both of these topics. Sometimes it is difficult for students to see these processes as three-dimensional and occurring concurrently. It is hoped that this case, and the questions posed by it, will give my students a framework to reinforce and conceptualize immune and inflammatory processes. Relationship Between Vertebrae, Spinal Nerves and Internal Organ FunctionsThe relationship of the various structures and systems is an important theme to me--and often lost to the student because of the systematic approach we take to teaching. This is compounded by the trimester nature of our teaching calendar. Often by the time students are studying the nervous system, they have long since moved beyond bone and internal organ structure and function. My goal in introducing this case in the third trimester would be to reconnect my students to material covered several months earlier. I would not introduce the case until close to the end of the semester, at which time we would have covered spinal cord anatomy, spinal nerves, and the autonomic nervous system. Mind/Body ConnectionThis is an area of great concern to my students and one that is richly covered in Chinese medicine. Ellen is a very depressed person--in Chinese medicine there may be a direct relationship between her emotional state and what is occurring structurally in her body. This is an area my students could explore for extra credit. I have often found that if I remain somewhat naïve to an area in Chinese medicine, my students rise to the occasion and teach me. As for students not involved in Chinese medicine, they may want to consider how alternative/complementary practitioners view this relationship when interviewing them. Alternative/Complementary MedicineIt has been my experience that people are often quick to jump to conclusions about alternative/complementary medicine without much exploration of the modalities. This works both ways: they either quickly embrace various forms of healing because of a great distrust of conventional medicine, or they quickly dismiss them, because there has not been much credible research in the area. This case provides an opportunity to establish some basis for understanding the strengths and weaknesses of a variety of alternative/complementary modalities. Scoliosis is a structural disorder that is chronic in nature, requiring a multidisciplinary approach to treatment. A variety of alternative/complementary approaches may be helpful in supporting Ellen, yet she might ultimately need to return for surgery. If well researched, the students should have a lively debate. CLASSROOM MANAGEMENTAs indicated before, I would lecture prior to distributing this case. The first half of questioning would be a take-home assignment. Students would be required to turn in the answers to these questions individually. Each group, however, will be given a modality to research, and are expected to come to class with an overview of that modality and a consensus as to how Ellen might be helped by it. I would think two weeks would be enough time to gather this information. Our classes run for three hours. I think one hour of this could be designated for case discussion. Of course, this depends also on how many groups are in the class. STUDENT RESEARCH RESOURCES• Keim, H.A., and R.N. Hensinger. 1989. Spinal deformities: scoliosis and kyphosis. Clinical Symposia 41(4) • Web search term - scoliosis Some web sites for Alt/Comp Medicine:
Editor's Note: Instructors interested in teaching this case may also want to browse issues of the Scientific Review of Alternative Medicine, published biannually by Prometheus Books, Amherst, NY, a good source for critical analysis of this type of information. Acknowledgements: This case study was developed with support from The Pew Charitable Trusts and the National Science Foundation as part of the Case Studies in Science Workshop held at the State University of New York at Buffalo on May 22-26, 2000. |