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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




The Case Study
case reports in the larger scheme of things
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
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Negative studies may not be published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
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 . . .
rct difficulties cont
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
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 200 direct hits?

May lead to clinical studies

Enter the lowly case report
case reports cont
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
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
Enter the chiropracticcase 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
“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
a case report is
“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 . . .
a case report is not
An anecdote

Def. - unpublished narrative

A testimonial

An advertisement

“Persuasive communication” (Keating)

A case report isnot. . .
kinds of major case reports
Unique cases: new conditions or treatments

e.g., new virus, or type of subluxation

Unexpected co-occurrence of two conditions - shared etiology?

e.g., MS with mitral valve prolapse

Unexpected outcome - usually adverse

e.g., HA w/ heel lift

To present pilot data

Kinds of major case reports
kinds of minor case reports
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
minor case reports cont
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
sample case reports classified
Sample case reports, classified
  • SMT for 12 pregnant LBP patients [Clinical Education]
  • Brucellosis: a rare cause of the unstable spine [clever chap]
  • RA: a case report [novel treatment]
  • Grand Rounds discussion: patient with acute LBP [Grand Rounds]
  • Rotary manipulation for cervical radiculopathy [unexpected association]
sample case reports cont
Sample case reports cont.
  • Mixed sacral fracture before chiropractic adjustment [unexpected outcome]
  • Membranous glomerulonephropathy associated with MS [unexpected occurrence]
  • Post-myelographic cauda equina in young acromegalic [unique case]
  • Arthritis and cetyl myristoleate [glorified advertisement]
  • Autism and chronic otitis media [anecdotal]
structure of a research article
Abstract: structured, 250 words

Introduction: the rationale

Methods: protocol, equip, stats

Results: visuals help

Discussion: opinions

Conclusion: the future

References: must be complete

Structure of a research article
functional components of a case report
Why case is worth reporting

What happened in the case

Evidence that case is unusual

Alternative explanations for what happened

Discussion, clinical implications

Functional Components of a case report

Tell them what you are going to say, say it, then tell them what you said.

formal sections of a case report
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 sections of a case report
formal sections cont
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(Discussion, conclusion can bevery short if there is an abstract.)
selecting a case
Case should illustrate an important point regarding case management (i.e., 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
performing a case study
Thinking time: deciding what to study

Literature search (Medline, MANTIS, etc.)

bibliographic databases, e.g. EndNote

Concept proposal

Performing a case study
performing a case study26
Performing a case study
  • Research design
    • defining successful outcome
    • selecting measures
      • surveys (questionnaires)
      • physiological measures
  • Execution
  • Publication
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
Do . . . cont.
  • Stick to basic format:
    • Introduction
    • Case description
    • Discussion
    • Conclusion
  • keep introduction and conclusion short, concentrate on the actualcase
don t

Name the subject(s)

Quote without reference

Cite books (articles better)

Say the “patient presented” (hackneyed)

Provide unnecessary detail

Occam’s Razor - One should not increase, beyond what is necessary, the number of entities required to explain anything

Don’t . . .
don t cont
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
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
introduction a closer look32
Introduction: A closer look
  • Literature search conducted
  • Usual clinical outcome, based on previous literature
  • Statement of purpose
    • Describe your purpose for writing the article
case description a closer look
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
case description a closer look34
Case description: A closer look
  • Diagnosis
  • Treatment
  • Clinical course
  • Outcome of care
discussion a closer look
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
conclusion a closer look
Need for further studies

Type of studies

Who would best conduct them


Implications for current clinical practice

Conclusion: A closer look

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)

manuscript preparation
Follow the editor’s guidelines explicitly

Illustrations must be of professional quality

Keep author(s) name off all but title page

Manuscript preparation
manuscript submission
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
manuscript submission cont
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
patient consent
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
case study designs
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
the case series
Variation on the theme of the solitary case report

Retrospective look at series of cases that have features in common

Common diagnosis, treatment, measures

In the literature already

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

The 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.
  • Fibromyalgia and Myofascial Pain Clinic of Portland
  • Case series study involving 22 patients with chronic low back pain

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).

single subject time series design tsd

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)
tsd cont
TSD cont.
  • AB design
    • Observation, intervention
  • ABA design (time series reversal design)
    • Observe, treat, observe, treat, etc.
using citation management software
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
  • 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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