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CASE REPORT Design Execution Reporting. The Case Study. The case may be an individual, an event, a policy, etc. e.g., a case of deafness and SMT (Harvey Lillard). Types of case studies. Case reports in the larger scheme of things:. Randomized clinical trial Cohort study

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The Case Study

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The case study l.jpg





The Case Study

Types of case studies l.jpg

The case may be an individual, an event, a policy, etc.

e.g., a case of deafness and SMT(Harvey Lillard)

Types of case studies

Case reports in the larger scheme of things l.jpg

Case reports in the larger scheme of things:

  • Randomized clinical trial

  • Cohort study

  • Case control study

  • Case reports

    • single subject time series designs

    • case series

    • single case

  • Expert opinions

The hierarchy of study designs

Case studies and reports are low on the totem pole l.jpg

Preliminary observations are frequently later refuted

May rationalize questionable treatments

e.g., thoracic SMT for deafness

Biased reporting

Negative studies may not be published

Not experimental

Except SS Time Series Design

Case studies and reports are low on the totem pole

When the gold standard loses its luster l.jpg

RCTs are hard and expensive to carry out!

Difficult to design an effective placebo

Treatment by nature involves multiple components

e.g., Ornish’s healthy heart regimen

e.g., CBP lordotic curve alteration

When the gold standard loses its luster . . .

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RCT difficulties (cont.)

  • Difficulty blinding participants

    • e.g., manipulation vs. massage

    • Everyone knows if they receive placebo

  • Randomization flaws

    • Recruiting patients from advertisements

    • Non-equivalent groups

  • Ethics involved in giving patients a placebo

Enter the lowly case report l.jpg

Not a clinical study per se, but high in clinical relevance

Well-done case reports may offer more than lousy clinical trials

In judging a prize fight, how to compare 300 light punches with 100 direct hits?

May lead to clinical studies

Enter the lowly case report

Case reports cont l.jpg

Case reports (cont.)

  • In rare or new pathologies, may be first evidence

    • e.g., Thalidomide and birth defects, toxic shock syndrome, Lyme disease

  • 20-30% of medical articles involve < 10 patients

Research value of case reports l.jpg

Illustrate or support a hypothesis

Atlas subluxation in a man with gastritis

Prompt a new hypothesis

Atlas subluxation can cause gastritis

Report treatment failures

Correcting atlas did not relieve gastritis

Report iatrogenic reactions

Gastritis better, but pt. developed brain tumor!

Research valueof case reports

Enter the chiropractic case report l.jpg

Enter thechiropracticcase report

  • A case generic to medical literature may be unique in chiropractic context

  • Chiropractic vs. medical (conventional) care

  • Uniqueness of a chiropractic perspective: “subluxation” vs. “non-specific LBP of mechanical etiology”

A definition from chiropractic journal of australia l.jpg

“Accounts of the diagnosis and treatment of unusual, difficult or otherwise interesting cases which may have independent educational value or may contribute to better standardization of care for a particular health problem when correlated with similar reports of others.”

A definition from Chiropractic Journal of Australia

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“Biomedical story-telling” (Lawrence, 1991)

A delivery vehicle for clinical education; indeed, “the case must have educational value” (Lawrence, 1991)

A stimulant for more comprehensive and prospective research

A case report is . . .

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An anecdote

Def. - unpublished narrative

A testimonial

An advertisement

“Persuasive communication” (Keating)

A case report isnot. . .

Kinds of major case reports l.jpg

Unique cases

New conditions or treatments

Unexpected association

Co-occurrence of two conditions - shared etiology?

Unusual presentation

A patient presents with a condition that is not typical

Unexpected development

usually adverse response to an intervention

Kinds of major case reports

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The “every one should remember” type:

Uncommon feature of an uncommon condition, like ankle edema w/Baker’s cyst

Grand rounds case:

Chiro. treatment of large disk herniation

“I-am-a-clever-chap” case:

How a lucky clinician found a clue to the correct diagnosis by accident

“Introducing the Subluxometer 5000!”

Kinds of minor case reports

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Minor case reports (cont.)

  • Variation-on-a-well-known-theme case:

    • 2 cases of SMT for ankylosing spondylitis

  • The Guinness-Book-of-World-Records case:

    • Usually describes a unique but irrelevant aspect of a well-recognized disease

    • e.g., carpal tunnel syndrome in a 100 year-old

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Sample case reports

  • Brucellosis: a rare cause of the unstable spine [clever chap]

  • RA: a case report [variation-well-known-theme]

  • Grand Rounds discussion: patient with acute LBP [Grand Rounds]

  • Membranous glomerulonephropathy associated with MS [unexpected co-occurrence]

  • Arthritis and cetyl myristoleate [advertisement]

  • Autism and chronic otitis media [unexpected co-occurrence ]

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Why the case is worth reporting

What happened in the case

Evidence that the case is unusual

Alternative explanations for what happened

Discussion, clinical implications

Functional Components of a case report

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Title: impressive and suggestive


How case came to light

Main features to report and why it deserves to be reported

Type of literature search

Formal sectionsof a case report

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Formal sections (cont.)

  • Case description: data, time line (amounts to methods and results)

    • Results of all relevant tests

    • Why other possible diagnoses were ruled out

    • Treatment

  • Discussion and Conclusion

    • May be separate or combined

    • Can be very short if there is an abstract

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Structure of a case study article

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Case should illustrate an important point regarding case management (e.g., examination, evaluation, intervention, outcome).

Case does not have to have a positive outcome

Case does not have to be unusual or unique

Selecting a case

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Thinking time: deciding what to study

Literature search (Medline, MANTIS, etc.)

Bibliographic databases, e.g. EndNote

Concept proposal

Performing a case study

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Performing a case study (cont.)

  • Research design

    • Defining a successful outcome

    • Selecting measures

      • questionnaires

      • physiological measures

  • Execution

  • Publication

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Find mentor or read related papers

Be aware of editor’s guidelines

Be brief

Choose relevant title

Use proper key (indexing) terms

Do . . .

Do cont l.jpg

Do . . . (cont.)

  • Stick to basic format:

    • Introduction

    • Case description

    • Discussion

    • Conclusion

  • Keep introduction and conclusion short, concentrate on the actualcase

Don t l.jpg


Name the subject(s)

Quote without reference

Cite books (articles better)

Say the “patient presented” (hackneyed)

Provide unnecessary detail

Don’t . . .

Occam’s Razor - One should not increase, beyond what is

necessary, the number of entities required to explain anything

Don t cont l.jpg

Don’t . . . (cont.)

  • Mix tenses or use jargon, like:

    • “This paper was written to relate how this patient is treated with . . .”

    • “head deviation”

  • Claim causality “proven”

  • Withdraw on 1st negative review

Introduction a closer look l.jpg

Know your audience, get their interest

Professional reviewers

General readers, in and out of chiropractic

Introduction components

Define the condition

How the case came to light

Main features to report

Introduction: A closer look

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Introduction: closer look (cont.)

  • Literature search conducted

  • Usual clinical outcome, based on previous literature

  • Statement of purpose

    • Describe your purpose for writing the article

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Describe the chief complaint

History of present illness

Past history

Physical examination findings

Laboratory examination

Special tests: radiology, MRI, ortho/neuro, etc.

Case description: A closer look

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Case description: A closer look (cont.)

  • Diagnosis

  • Treatment

  • Clinical course

  • Outcome of care

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Significance of the case

Personal interpretation and opinions

Compare current case with cases and studies previously reported

Limitations of the study

Very important!

Be objective, not defensive

Discussion: A closer look

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Need for further studies

Type of studies

Who would best conduct them


Implications for current clinical practice

Conclusion: A closer look

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New discoveries

Challenges accepted models

Basic method of sharing observations


Limited generalizability

Not able to determine causes (no control)

Observations usually influenced by unmeasured factors (confounders)

In summary

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Follow the editor’s guidelines explicitly

Illustrations must be of professional quality

Keep author(s) name off all but title page

Manuscript preparation

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Editor determines potential for publication

Returned to author for more work, or

Sent to 2 or more blinded reviewers/referees

Comments returned to author

Annotated manuscript

Reviewer’s written comments

Editor’s summary of criticisms

Manuscript submission

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Manuscript submission (cont.)

  • Paper re-submitted (hopefully)

    • Almost all manuscripts are returned for revisions, so don’t be discouraged

  • Galley proofs follow

  • Sometimes further questions

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Manuscript submission (cont.)

Patient consent l.jpg

It is usually not necessary to obtain a separate patient consent to use the file data for a case study

JMPT recently started to require consent for case reports

Patient consent is needed if you plan on publishing pictures of the patient and the patient can be identified from the photos

X-rays don’t count, just don’t include the name

Patient Consent

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One shot case study

Intervention then outcome assessment

Pre-test, post-test study

Initial measurement, intervention, outcome assessment

Single-subject Time-series

Repeated measures on and off the treatment

Case study designs

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Variation on the theme of the solitary case report

Retrospective look at series of cases that have features in common

Common diagnosis, treatment, measures

Each case may be separately described, or the cases may be lumped together with data summaries

The case-series

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Example case series

  • McMakin, C.R., Microcurrent therapy: a novel treatment method for chronic low back myofascial pain. Journal of Bodywork and Movement Therapies, 2004. 8(2): p. 143-53.

  • Carolyn R. McMakin, M.A., D.C.

  • Case series study involving 22 patients with chronic low back pain

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Table 1 Outcomes in chronic low back pain patients.

Clinical outcome Average Standard Range

(n = 22) deviation

Number of treatments 5.7 4.0 2–10

Treatment duration (weeks) 5.6 4.5 1–10

Pre-treatment pain 6.5/10 1.2/10 3–9

Post-treatment pain 1.7*/10 1.4/10 0–5

Chronicity (years) 8.8 5.4 1.5–20

* Statistically significant difference from pre-treatment mean (P < 0.005).

Slide45 l.jpg

  • Reporting median would have been better

  • Statistical comparisons?

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Repeated measures (at least 3)

May show trend in baseline

Identifies treatment impact during treatment phase

Does not address acute patients

Single-subject Time Series Design (TSD)

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TSD (cont.)

  • AB design

    • Observation, intervention

  • ABA design (time series reversal design)

    • Observe, treat, observe, treat, etc.

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Using citation management software

  • Examples are EndNote, ProCite, and RefWorks

  • Organize citations and format bibliographies

    • specific journal styles, APA, etc.

  • Search online databases and download directly to your computer

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  • Invaluable when writing any kind of report that uses references

    • Case reports

    • Review articles for local newsletters and journals

    • Med-legal reports

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Works with word processor

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Click to go to EndNote

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Find Norris reference by searching or typing first letters of last name

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Place cursor

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Citation added

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Search term

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