The Case ReportThe Case Report

Lisa Zaynab Killinger, DCLisa Zaynab Killinger, DC

Palmer Center Palmer Center

for Chiropractic Researchfor Chiropractic Research

What is a “Case Report” What is a “Case Report” or “Case Study”?or “Case Study”? A report on the case history, A report on the case history,

management, and/or results seen in management, and/or results seen in one or more patient.one or more patient.

OR...OR...Describe the identification, Describe the identification,

management, or unusual presentation management, or unusual presentation of a condition of interest.of a condition of interest.

Case Reports...Case Reports... Should have an educational value to the Should have an educational value to the

reader, sharing your experience with reader, sharing your experience with othersothers

Are the foundation for future studiesAre the foundation for future studies Are “healthcare story telling”Are “healthcare story telling” Have clinical education valueHave clinical education value

Case Reports are written Case Reports are written to describe..to describe..

An unusual occurrence or presentationAn unusual occurrence or presentation An unexpected outcome (The Good, the An unexpected outcome (The Good, the

Bad, or the Ugly!)Bad, or the Ugly!) A new approach to an old problemA new approach to an old problem

Why Should I Publish Why Should I Publish A Case Report???A Case Report???

Where does the case report Where does the case report fall in the hierarchy of fall in the hierarchy of

evidence?evidence?

Levels of evidenceLevels of evidence

Meta- Analyses

RCTs

Other Experimental

Quasi-Experimental

Observational

Case reports/Clinical observations

Chiropractic Research: Chiropractic Research: Levels of EvidenceLevels of Evidence

Meta-Analyses

RCTsOther Experimental

Quasi-Experimental

Observational

Case reports

Limitations of Case Reports:Limitations of Case Reports:

Not generalizableNot generalizable Describes what happened in one case, Describes what happened in one case,

nothing more.nothing more. Does not rule out placebo effectDoes not rule out placebo effect Does not prove effectiveness of Does not prove effectiveness of

treatmenttreatment

Anatomy of a Case ReportAnatomy of a Case Report AbstractAbstract IntroductionIntroduction Methods/Case Report*Methods/Case Report* Intervention and OutcomeIntervention and Outcome DiscussionDiscussion ConclusionsConclusions

IntroductionIntroduction Introduces the case/condition of interestIntroduces the case/condition of interest Reviews and cites the scientific literature Reviews and cites the scientific literature

on the topic (Chiro./Non-chiro. Lit.) on the topic (Chiro./Non-chiro. Lit.) States the etiology/common txs./prognosis States the etiology/common txs./prognosis Includes Includes recentrecent, high quality references , high quality references

(articles are better than books!)(articles are better than books!)

The Introduction Section The Introduction Section AnswersAnswers::

What is known about the condition What is known about the condition of interest?of interest?

Case Report or Clinical Case Report or Clinical FeaturesFeatures

Describes the history and examination of Describes the history and examination of the patient the patient

`̀ (Thoroughly enough to (Thoroughly enough to convince the reader that the doctor convince the reader that the doctor responsibly arrived at the appropriate responsibly arrived at the appropriate clinical impression and management clinical impression and management plan!)plan!)

The Case Report The Case Report Section Answers:Section Answers:

How did patient present, what How did patient present, what were your exam findings, and were your exam findings, and

what was your diagnosis?what was your diagnosis?

Methods orMethods orIntervention & OutcomeIntervention & Outcome

This section must describe the care This section must describe the care given in enough detail that the reader given in enough detail that the reader could easily duplicate the care. (And, could easily duplicate the care. (And, hopefully, duplicate your outcomes!)hopefully, duplicate your outcomes!)

The Intervention & The Intervention & Outcome (Methods) Outcome (Methods)

Section Answers:Section Answers:

What did you do, when, What did you do, when, and how?and how?

The Outcome PieceThe Outcome Piece Describe the changes observed in the pt.Describe the changes observed in the pt.

Lists results on outcome measures used Lists results on outcome measures used (I.e: Rand-36 or Visual Analog scores)(I.e: Rand-36 or Visual Analog scores)

Describes changes in health status, pain, Describes changes in health status, pain, symptoms, unexpected results, etc.symptoms, unexpected results, etc.

The Outcome (Results) The Outcome (Results) Section Answers:Section Answers:

How did you document How did you document changechange (positive or negative (positive or negative

results) in this case?results) in this case?

Discussion Includes:Discussion Includes: Interpretations of your findingsInterpretations of your findings Comparison of your case with other studies Comparison of your case with other studies

(The ones cited in your intro!)(The ones cited in your intro!) Rationale for management planRationale for management plan Discussion of limitations/flaws in your studyDiscussion of limitations/flaws in your study Discuss possible reasons for the results you Discuss possible reasons for the results you

observed (other variables,placebo, etc.)observed (other variables,placebo, etc.)

The Discussion Section The Discussion Section AnswersAnswers::

How does your case How does your case confirm/refute previous studies confirm/refute previous studies

on this topic, and why did you do on this topic, and why did you do what you did?what you did?

ConclusionsConclusions Tells the reader what was learned through Tells the reader what was learned through

this case this case

Describes why the case is significantDescribes why the case is significant

Suggests a direction for future studies. Suggests a direction for future studies.

Caution: Don’t make unsubstantiated Caution: Don’t make unsubstantiated claims!!!claims!!!

The Conclusion Section The Conclusion Section Answers:Answers:

What is the next stepWhat is the next step

in studying this topic?in studying this topic?

Measures of Quality Measures of Quality in Case Reports:in Case Reports:

Use of outcomes assessmentsUse of outcomes assessments Lengthy follow-upLengthy follow-up Discussion of its limitations! (If Discussion of its limitations! (If

you don’t, the reviewers/readers you don’t, the reviewers/readers will!)will!)

More Measures of Quality:More Measures of Quality:

Description of the methods Description of the methods A good literature reviewA good literature review Discussion of the placebo effectDiscussion of the placebo effect Good quality, recent references!!Good quality, recent references!!

What in the heck are What in the heck are outcome assessments?outcome assessments?

Visual Analog Scale :VASVisual Analog Scale :VAS(Global Well-Being Scale, etc.)(Global Well-Being Scale, etc.)

Simply a 10 cm. lineSimply a 10 cm. line

Rand-36Rand-36(SF-36)(SF-36)

A 36 question survey; patient fills it outA 36 question survey; patient fills it out A A valid and reliablevalid and reliable measure of the measure of the

patient’s general health statuspatient’s general health status A shorter 12 question form is availableA shorter 12 question form is available Offers a great deal of information on Offers a great deal of information on

patients’ emotional and physical well patients’ emotional and physical well being, energy, pain, etc.being, energy, pain, etc.

What makes an outcome What makes an outcome measure or assessment tool measure or assessment tool

‘good’?‘good’?

A Word About ReferencesA Word About References References should be numbered in the order References should be numbered in the order

they appear in the articlethey appear in the article References need to be listed immediately References need to be listed immediately

following the sentence (or phrase) that comes following the sentence (or phrase) that comes from another author or article.from another author or article.

All statements of fact should be referenced.All statements of fact should be referenced. Research articles are preferred, then Research articles are preferred, then

textbooks, then manuals, popular press textbooks, then manuals, popular press articles, etc.articles, etc.

Style…Scientific Style…Scientific Pulications/ArticlesPulications/Articles

Author’s Last name then first initial, Author’s Last name then first initial, <comma> other authors “ ‘’<Period> Title <comma> other authors “ ‘’<Period> Title of article (only first letter capitalized) of article (only first letter capitalized) <period> N<period> Name of Journalame of Journal (using standard (using standard abbrev and italicized) <period>year of abbrev and italicized) <period>year of publication <semicolon>volume number publication <semicolon>volume number and issue number (issue # in and issue number (issue # in parentheses)<colon>page numbers parentheses)<colon>page numbers <period><period>

Hurwitz EL, Coulter ID, Hurwitz EL, Coulter ID, Adams AH, et al. Use of Adams AH, et al. Use of

chiropractic services from chiropractic services from 1985-1991 in the United States 1985-1991 in the United States

and Canada. and Canada. Am J Public Am J Public HealthHealth. 1998;88(5):771-776.. 1998;88(5):771-776.

Style-TextbooksStyle-Textbooks

Author last name and first Author last name and first initial<period>initial<period>NameName of Bookof Book (Italicized; (Italicized; with each main word capitalized) with each main word capitalized) <period>Edition number <period>Edition number <period>City/country of publication <period>City/country of publication <colon>Publisher’s name <semicolon>Year <colon>Publisher’s name <semicolon>Year of pubication <colon> page numbers of pubication <colon> page numbers <period><period>

Peters T. Peters T. The Pursuit of Wow!The Pursuit of Wow! New York:Vintage Books;1994.New York:Vintage Books;1994.

Some things NOT to do when Some things NOT to do when writing a case report...writing a case report...

DON’TDON’T

Write as if you are promoting your product/ Write as if you are promoting your product/ clinic (case reports are not advertisements)clinic (case reports are not advertisements)

Submit without you AND others proofreading Submit without you AND others proofreading your paperyour paper

Use patient’s or doctor’s nameUse patient’s or doctor’s name Try to generalizeTry to generalize Say that you “proved effectiveness” of a tx.Say that you “proved effectiveness” of a tx.

Where Should You Publish?Where Should You Publish? Decide on who you want to reach:Decide on who you want to reach: Large audience? Large audience?

Clinicians? Educators? Chiropractors? Other health professionals? Clinicians? Educators? Chiropractors? Other health professionals? Your best quality work: Submit to ‘Peer- reviewed’, and indexed Your best quality work: Submit to ‘Peer- reviewed’, and indexed

journals.journals. Inexperienced writers: Get help, so you can submit to peer reviewed Inexperienced writers: Get help, so you can submit to peer reviewed

journals.journals. Study the requirements/guidelines for submission of various journals. Study the requirements/guidelines for submission of various journals.

Some Peer-Reviewed Some Peer-Reviewed Chiropractic JournalsChiropractic Journals

JMPT-Peer-reviewed and indexed in Medline +JMPT-Peer-reviewed and indexed in Medline +

JNMS-P.R and indexed in CINAHL + (gone)JNMS-P.R and indexed in CINAHL + (gone)

Topics in Clin. Chiro.-PR, CINAHL + (gone)Topics in Clin. Chiro.-PR, CINAHL + (gone)

ICA J. of Clinical Pediatrics – PR (gone)ICA J. of Clinical Pediatrics – PR (gone)

Some Non Peer-Reviewed Some Non Peer-Reviewed Chiropractic “Journals”Chiropractic “Journals”

ACA JournalACA Journal ICA JournalICA Journal The Chiropractic Journal (newspaper)The Chiropractic Journal (newspaper) Dynamic Chiropractic (newspaper)Dynamic Chiropractic (newspaper)

The Morning After The Morning After (Or, what happens AFTER you (Or, what happens AFTER you

submit to a journal)submit to a journal)

Well, you wait…..Well, you wait…..

What Then?What Then?

Reviewers are selected to read your Reviewers are selected to read your article.article.

Reviewers make formal comments, and Reviewers make formal comments, and give opinions on the paper’s give opinions on the paper’s publishability.publishability.

You get reviewer comments/suggestions.You get reviewer comments/suggestions.

You Do This...You Do This...

Afterwards ...Afterwards ...

You make your revisions.You make your revisions. You re-submit.You re-submit. You get a “galley proof”.You get a “galley proof”. You look it over again.You look it over again. You submit your You submit your briefbrief last minute last minute

changes.changes.

And Finally, You Get Published!And Finally, You Get Published!

For more information on case For more information on case report writing:report writing:

Contact Lisa Killinger, DCContact Lisa Killinger, DC1-(563)-884-58541-(563)-884-5854

(Or look for articles on this topic in (Or look for articles on this topic in the scientific literature!)the scientific literature!)

What’s wrong with this What’s wrong with this picture?picture?

“ “ ......This case study This case study demonstrates that chiropractic demonstrates that chiropractic

is an effective treatment for is an effective treatment for multiple sclerosis.”multiple sclerosis.”

““......In this case, chiropractic In this case, chiropractic adjustments to the upper adjustments to the upper

cervical spine were effective in cervical spine were effective in resolving the infantile colic.”resolving the infantile colic.”

Asthma is the most common Asthma is the most common chronic condition in children, chronic condition in children,

responsible for staggering responsible for staggering healthcare expenditures, and healthcare expenditures, and

thousands of deaths per year in thousands of deaths per year in this country alone. (?)this country alone. (?)

““The cervical films showed aThe cervical films showed a C3 PRI.” C3 PRI.”

What goes where?What goes where?

For each sentence that follows, For each sentence that follows, decide into which section of the decide into which section of the case study (e.g: methods, intro) case study (e.g: methods, intro) it would most appropriately fit.it would most appropriately fit.

In this case, we observed a In this case, we observed a decrease in the number and decrease in the number and

severity of headaches…..severity of headaches…..

Asthma is the most common Asthma is the most common chronic condition in children, chronic condition in children,

responsible for staggering responsible for staggering healthcare expenditures, and healthcare expenditures, and

thousands of deaths per year in thousands of deaths per year in this country alone.this country alone.

Recent studies have shown Recent studies have shown chiropractic care to be an chiropractic care to be an

effective treatment for chronic effective treatment for chronic tension-type headaches. (13, 14) tension-type headaches. (13, 14)

The results observed in this The results observed in this case, confirm the findings of case, confirm the findings of

these earlier studies.these earlier studies.

Typically, medical Typically, medical management of asthma consists management of asthma consists

primarily of pharmaceutical primarily of pharmaceutical interventions including....interventions including....

The examination of this patient The examination of this patient revealed a positive Cervical revealed a positive Cervical

Compression test, and….Compression test, and….