The Case Study

1. CASE REPORT Design Execution Reporting The Case Study

2. 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

3. 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

4. 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refuted May rationalize questionable treatments e.g., thoracic SMT for deafness Biased reporting Negative studies may not be published Not experimental Except SS Time Series Design Case studies and reports are low on the totem pole

5. 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 . . .

6. 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

7. 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

8. 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

9. 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

10. 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”

11. “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

12. “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 . . .

13. An anecdote Def. - unpublished narrative A testimonial An advertisement “Persuasive communication” (Keating) A case report isnot. . .

14. 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

15. 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

16. 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

17. 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]

18. 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]

19. 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

20. 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.

21. Title: impressive and suggestive Introduction: 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

22. 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.)

23. Structure of a case study article

24. 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

25. Thinking time: deciding what to study Literature search (Medline, MANTIS, etc.) bibliographic databases, e.g. EndNote Concept proposal Performing a case study

26. Performing a case study • Research design • defining successful outcome • selecting measures • surveys (questionnaires) • physiological measures • Execution • Publication

27. Find mentor or read related papers Be aware of editor’s guidelines Be brief Choose relevant title Use proper key (indexing) terms Do . . .

28. Do . . . cont. • Stick to basic format: • Introduction • Case description • Discussion • Conclusion • keep introduction and conclusion short, concentrate on the actualcase

29. Apologize 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 . . .

30. 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

31. 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

32. Introduction: A closer look • Literature search conducted • Usual clinical outcome, based on previous literature • Statement of purpose • Describe your purpose for writing the article

33. 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

34. Case description: A closer look • Diagnosis • Treatment • Clinical course • Outcome of care

35. 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

36. Need for further studies Type of studies Who would best conduct them Obstacles Implications for current clinical practice Conclusion: A closer look

37. Strengths New discoveries Challenges accepted models Basic method of sharing observations Weaknesses Limited generalizability Not able to determine causes (no control) Observations usually influenced by unmeasured factors (confounders) Summary

38. Follow the editor’s guidelines explicitly Illustrations must be of professional quality Keep author(s) name off all but title page Manuscript preparation

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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).

46. Reporting median would have been better No statistical comparisons

47. Quasi-experimental 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)

48. TSD cont. • AB design • Observation, intervention • ABA design (time series reversal design) • Observe, treat, observe, treat, etc.

49. 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

50. EndNote • Invaluable when writing any kind of report that uses references • Case reports • Review articles for local newsletters and journals • Med-legal reports