The Case Study

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The Case Study

• CASE REPORT
• Design
• Execution
• Reporting

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Types of case studies

• The case may be an individual, an event, a
  policy, etc.
• e.g., a case of deafness and SMT(Harvey Lillard)

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Case reports in the larger scheme of things
The hierarchy of study designs

• Randomized clinical trial
• Cohort study
• Case control study
• Case reports
• single subject time series designs
• case series
• single case
• Expert opinions

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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• Negative studies may not be published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

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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., Ornishs healthy heart regimen
• e.g., CBP lordotic curve alteration

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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

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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

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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 lt 10 patients

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Research valueof 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!

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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

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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.

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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

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A case report is not . . .

• An anecdote
• Def. - unpublished narrative
• A testimonial
• An advertisement
• Persuasive communication (Keating)

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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

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Kinds of minor case reports

• The every one should remember type
• Uncommon feature of an uncommon condition, like
  ankle edema w/Bakers 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!

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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, 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

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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

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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

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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

Tell them what you are going to say, say it, then
tell them what you said.
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Formal sections of a case report

• 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

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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(Discussion,
  conclusion can bevery short if there is an
  abstract.)

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Structure of a case study article
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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

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Performing a case study

• Thinking time deciding what to study
• Literature search (Medline, MANTIS, etc.)
• bibliographic databases, e.g. EndNote
• Concept proposal

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Performing a case study

• Research design
• defining successful outcome
• selecting measures
• surveys (questionnaires)
• physiological measures
• Execution
• Publication

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Do . . .

• Find mentor or read related papers
• Be aware of editors guidelines
• Be brief
• Choose relevant title
• Use proper key (indexing) terms

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Do . . . cont.

• Stick to basic format
• Introduction
• Case description
• Discussion
• Conclusion
• keep introduction and conclusion short,
  concentrate on the actual case

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Dont . . .

• Apologize
• Name the subject(s)
• Quote without reference
• Cite books (articles better)
• Say the patient presented (hackneyed)
• Provide unnecessary detail
• Occams Razor - One should not increase, beyond
  what is necessary, the number of entities
  required to explain anything

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Dont . . . 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

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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

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Introduction A closer look

• Literature search conducted
• Usual clinical outcome, based on previous
  literature
• Statement of purpose
• Describe your purpose for writing the article

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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.

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Case description A closer look

• Diagnosis
• Treatment
• Clinical course
• Outcome of care

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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

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Conclusion A closer look

• Need for further studies
• Type of studies
• Who would best conduct them
• Obstacles
• Implications for current clinical practice

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Summary

• 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)

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Manuscript preparation

• Follow the editors guidelines explicitly
• Illustrations must be of professional quality
• Keep author(s) name off all but title page

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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
• Reviewers written comments
• Editors summary of criticisms

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Manuscript submission cont.

• Paper re-submitted (hopefully)
• Almost all manuscripts are returned for
  revisions, so dont be discouraged
• Galley proofs follow
• Sometimes further questions

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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 dont count, just dont include the name

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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

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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

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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

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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 4.0 210 Treatment duration
(weeks) 5.6 4.5 110
Pre-treatment pain 6.5/10 1.2/10
39 Post-treatment pain 1.7/10 1.4/10
05 Chronicity (years) 8.8 5.4
1.520 Statistically significant
difference from pre-treatment mean (P lt 0.005).
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Reporting median would have been better No
statistical comparisons
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Single-subject Time Series Design (TSD)

• Quasi-experimental
• Repeated measures (at least 3)
• May show trend in baseline
• Identifies treatment impact during treatment
  phase
• Does not address acute patients

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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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EndNote

• 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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first letters of last name
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