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Presenting Clinical Case Studies, Simplified
Educate MDs about chiropractic by presenting relevant clinical cases.
By Christina Acampora, DC
Many medical physicians understand and experience frustration along with their patients who struggle with chronic back and neck pain. What these physicians aren’t familiar with is what happens when the patient tries chiropractic care—often as a last resort. Clinical case studies can help them understand what chiropractic can do for their patients. Presenting cases that focus on a difficult or chronic condition gives you visibility as a specialist in treating spinal conditions without resorting to medications and often preventing surgery. The following points will be of interest to MDs when you present a clinical case.
Patient’s Case and History of Care
For most physicians, the beginning of the case will sound quite familiar—the patient fails to respond or plateaus with traditional treatments. Describe the patient’s presentation to your office and take listeners through a straightforward and easy-to-follow history. What was the original presentation of the patient’s pain, what caused the condition and what treatments had the patient sought?
Note the impact these past treatments had on the patient’s condition, both positive and negative. Was the patient compliant? Physicians know that patients don’t always follow through with physical therapy referrals or take the medication that was prescribed. Mention how long the patient has struggled with the condition. Include copies of X-rays, MRIs and any other reports, omitting the patient’s identifying information.
Next, describe the patient’s presentation to your office. Share both subjective and objective data that help illustrate the severity and nature of the pain. Take physicians through your diagnostic and testing approach, including any Oswestry, Neck Disability Index, Visual Analog Scales and other pain rating scores. When providing a summary of objective examination findings, include negative ones. Instead of listing each negative test individually, indicate which orthopedic and neurological tests were unremarkable. If you feel that the history and subsequent treatment warrant further explanation of negative findings, to illustrate that you ruled out progressive neurological symptoms, you can state, for example, “neurological testing was unremarkable, including lower-extremity sensory and motor testing.”
Treatment and Patient Response
Describe the treatments and summarize their frequency, location and duration, as well as the impact they had on pain and disability. For instance, your treatment may have included manipulation to the lower back and pelvis region that you administered on a bi-weekly basis over a three-week period, with the resulting 50-percent reduction of baseline Oswestry scores. Next, you continued manipulation once a week for four weeks and encouraged an active exercise regime, which the patient was intermittently compliant with, resulting in another 30-percent reduction in Oswestry scores.
In addition to listing the patient’s progress through Oswestry or other self-assessment tools that rate pain and disability, indicate the impact on the patient’s activities of daily living as a result of the treatment. Try to relate as much information as you can back to the patient.
Include all treatments and the clinical rationale behind why you may or may not have provided physical therapy, exercises, positive reinforcement of pain management and so on. Note that some chiropractic-specific terms, such as “subluxation,” may cause confusion. Rather, try using “joint dysfunction” in place of subluxation, and “advanced muscular therapy,” in place of “trigger point therapy” or Graston Technique,® to avoid confusion.
Another option to use when organizing a clinical case presentation is a PICO (problem/disorder, intervention, comparison, outcome) format. This is a common method that physicians use when conducting a literature search to answer a clinical question on managing a specific patient. See an example of presenting a case of treating chronic lower-back pain in a 68-year-old female patient with a history of stroke in the table (Fig.1):
PICO element Explanation Example
Problem/disorder Describe the patient’s problem or condition 68-year-old female with lower-back pain and history of a stroke
Intervention Explain the intervention, such as a test or treatment Chiropractic manipulation of the lower back
Comparison Mention alternative treatment, no treatment or test NSAIDs
Outcome Describe the outcome of the intervention Reduced pain, fewer side effects
Research can help support the benefits of chiropractic care. If you presented a case on chronic lower-back pain, consider summarizing a research study that focuses on the use of manipulation for chronic back pain briefly at the end of your presentation. Alternatively, illustrate research on the mechanism of action of spinal manipulation, which will help emphasize why your treatment was successful.1
Depending on the number of interesting cases, you can also summarize several similar cases during a presentation—or present a summary of research, rather than a case study. In addition to making formal presentations to individual physicians or medical groups, you can shine a positive light on the benefits of chiropractic care in other formats. Consider sharing a condensed version of a case study in a medical newsletter—or publishing a case report in a chiropractic journal, such as JMPT or JACA Online, which you can later share with your medical colleagues. (Editor’s Note: Read about presenting research to medical physicians in the Jan. 2010 issue of ACA News at www.acatoday.org/acanews. To access JMPT and JACA, go to www.acatoday.org/jmpt and www.acatoday.org/jaca.)
1. Maigne JY, Vautravers P. Mechanism of action of spinal manipulative therapy. Joint Bone Spine 2003;70:336–341.
ACA News Extra...
Consider Attending Grand Rounds
Clinical case studies can be presented in a one-on-one setting or to a group of physicians. Grand rounds—mini-lectures or case presentations on specific topics—are especially appealing because they commonly take place at teaching hospitals, as well as some smaller local community hospitals across the country.
Presenting a clinical case study in front of a group can help you educate physicians on the chiropractic approach to managing back pain and other conditions. A difficult case in severity of pain, level of disability or co-existing conditions (which complicate treatment) that was resolved by chiropractic care will be of interest. In addition to expanding your own knowledge base, grand rounds can offer you opportunities to network and establish yourself as a local health care expert. If a grand rounds topic is related to the conditions that you can treat, chances are, the physicians attending these talks are doctors you want to talk to as possible referral sources.
Depending on the hospital, these lectures take place during the lunch hour weekly, bi-monthly or monthly. There is no charge to attend. To find local grand rounds, try a Google search, such as “(name of your local hospital) grand rounds schedule” to get a contact name at the hospital and a schedule of upcoming lectures. Or call the hospital and ask for the person in charge of continuing education, physician lectures or grand rounds. If you already have established relationships with physicians, ask them for more information.