How to do Case ReportsHow to do Case Reports

Albert Moraska, PhDAlbert Moraska, PhDAssistant Research ProfessorAssistant Research Professor

University of Colorado Health Sciences University of Colorado Health Sciences CenterCenter

OutlineOutline

Conducting a Case ReportConducting a Case Report

Summarizing your findingsSummarizing your findings

Insights into the Review Process Insights into the Review Process

Goals of Case Reports Submitted Goals of Case Reports Submitted for Journal Publicationfor Journal Publication

Increase research literacyIncrease research literacy

Stimulate researchStimulate research

Provide forum for individuals to present Provide forum for individuals to present their experiencestheir experiences

Enhance professional developmentEnhance professional development

Why do a Case Report?Why do a Case Report?

Responsibility of a professionResponsibility of a profession

Forward the field / Gain acceptanceForward the field / Gain acceptance

Share informationShare information

Value of a Case ReportValue of a Case Report

Case Report

Pilot / Feasibility Study

Small Clinical Trial

Large Multi-Center Clinical Trial

Marshall’s Case ReportMarshall’s Case Report

Attempt to fulfill Koch's postulates for pyloric Campylobacter

Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ.

A volunteer with histologically normal gastric mucosa received pyloric campylobacter by mouth. A mild illness developed, which lasted 14 days. Histologically proven gastritis was present on the tenth day after the ingestion of bacteria, but this had largely resolved by the fourteenth day. The syndrome of acute pyloric campylobacter gastritis is described. It is proposed that this disorder may progress to a chronic infection which predisposes to peptic ulceration.

Med J Aust. 1985 Apr 15;142(8):436-9.

Conducting a Case ReportConducting a Case Report

Identifying a research topicIdentifying a research topic

Prospective or retrospective Prospective or retrospective

Locate a subjectLocate a subject– ClientsClients– Family / friendsFamily / friends– Medical referralMedical referral

Has this topic been reported before?Has this topic been reported before?

Is this a topic that others would be Is this a topic that others would be interested in?interested in?

Ideas for (simple) measurementsIdeas for (simple) measurements

Consult the literatureConsult the literature

Visual Analog ScalesVisual Analog Scales

GoniometersGoniometers

Clinical significanceClinical significance

Other simple measures: Other simple measures: – number of steps, number of steps, – number of hours slept, number of hours slept, – number of hours in pain, etc. number of hours in pain, etc.

Summarizing Your FindingsSummarizing Your Findings

Writing the Case ReportWriting the Case Report

Abstract (6 pts)Abstract (6 pts)

Introduction (25 pts)Introduction (25 pts)

MethodsMethods– Profile of Client (10 pts)Profile of Client (10 pts)– Treatment Plan (15 pts)Treatment Plan (15 pts)

Results (15 pts)Results (15 pts)

Discussion (20 pts)Discussion (20 pts)

ReferencesReferences

Other documentationOther documentation

The Case Report - AbstractThe Case Report - Abstract

Brief summary – 200 word limitBrief summary – 200 word limit– ObjectiveObjective– MethodsMethods– ResultsResults– ConclusionConclusion

Used by indexing servicesUsed by indexing services

Key wordsKey words

The Case Report - IntroductionThe Case Report - Introduction

Build an argument for doing the studyBuild an argument for doing the study

Background to understand topicBackground to understand topic

Justification for why treatment should Justification for why treatment should benefit benefit

Arguments supported by the literatureArguments supported by the literature

Not an exhaustive review Not an exhaustive review

About 250-500 wordsAbout 250-500 words

The Case Report - MethodsThe Case Report - Methods

Client ProfileClient Profile

Treatment PlanTreatment Plan– Description of treatment techniques used, Description of treatment techniques used,

treatment duration, etc.treatment duration, etc.– Don’t mix in any resultsDon’t mix in any results

Evaluation ProceduresEvaluation Procedures

Sufficient detail such that someone could Sufficient detail such that someone could “repeat the study”“repeat the study”

The Case Report - ResultsThe Case Report - Results

Presenting the dataPresenting the data– In the text - briefly (100-200 words) describe In the text - briefly (100-200 words) describe

any particularly interesting finding and refer any particularly interesting finding and refer to:to:

– Tables Tables great for complex data setsgreat for complex data sets

– Figures Figures great for visual effect great for visual effect

need a figure captionneed a figure caption

Data Presentation StylesData Presentation Styles

Hip Abduction

10

15

20

25

30

35

40

45

50

Baselin

e - P

re

Baselin

e - P

ost

Game

1 - P

re

Game

1 - P

ost

Game

2 - P

re

Game

2 - P

ost

Game

3 - P

re

Game

3 - P

ost

Game

4 - P

re

Game

4 - P

ost

Game

5 - P

re

Game

5 - P

ost

Deg

rees

A - Right

A - Left

B - Right

B - Left

Linear (A - Right)

Linear (A - Left)

Linear (B - Right)

Linear (B - Left)

Don’t be overly complexDon’t be overly complex

Data Presentation StylesData Presentation Styles

Make sure the data you want to get across is Make sure the data you want to get across is easily obtainable by the readereasily obtainable by the reader

Session

Movement 1 2 3 4 5 6 7 8 9 10 Flexion of Elbow 3 1 3 3 3 3 3 2 2 3

Extension of Elbow 3 2 3 4 3 3 3 4 2 3 Supination (Arm straight) 5 4 5 5 4 5 5 4 3 4 Supination (Arm straight/closed fist)

x 6 6 7 5 5 5 4 3 4

Supination (Arm flexed) 3 3 5 5 4 3 3 3 3 3 Pronation (arm straight) 4 4 4 4 4 5 5 4 4 4 Pronation (Arm straight/closed fist)

x 5 5 6 5 5 4 5 4 4

Pronation (Arm flexed) 3 3 3 3 3 4 4 5 4 4

Ulnar Deviation 3 4 5 5 5 5 5 5 5 4 Radial Deviation 4 5 6 6 5 4 4 5 5 4

Digit Extension 4 3 4 5 5 5 5 5 3 3 Wrist Extension 5 5 4 5 6 5 5 4 4 3

Data Presentation StylesData Presentation Styles

Don’t use 3-Dimensional graphsDon’t use 3-Dimensional graphs

Data Presentation StylesData Presentation Styles

Figure 3 Figure 4

Use fixed measurement references

Data Presentation StylesData Presentation Styles

Changes in Postural Measures

02468

10121416

1 2 3 4 5

Treatment Number

Po

sit

ion

(c

m) Forward

HeadCarriage

InternalRotation ofShoulders

Figure 1. Changes in postural measures of Forward head Carriage (FHC) and Internal Rotation of shoulders. FHC was measured in cm from the Occiput to the wall. Internal rotation was measured from the inferior tubercle of the humerus to the wall.

The Case Report - DiscussionThe Case Report - Discussion

Provide meaning to the data:Provide meaning to the data:– Why was this study important?Why was this study important?– What previous unknown is now known?What previous unknown is now known?

Critically evaluate the dataCritically evaluate the data– Describe strengths and limitationsDescribe strengths and limitations

e.g. only used one form treatment e.g. only used one form treatment

Are there more accurate evaluation methods?Are there more accurate evaluation methods?

– Relate findings to other similar studiesRelate findings to other similar studies e.g. compare to other types of treatmentse.g. compare to other types of treatments

The Case Report - DiscussionThe Case Report - Discussion

Your Finding: Systolic BP changes from 160 to 125 mmHg following CST

HypothesisTreatment had an effect!

Alternative HypothesisLying on a table for

60 min could cause the reduction

CounterSmith et al (2005) found that resting

quietly only reduces BP by 5 mmHg for those with moderately elevated BP

Hypothetical Example #1

The Case Report - DiscussionThe Case Report - Discussion

Your finding: Grip strength increased from 20kg to 28kg following treatment

Hypothetical Example #2

Increase is similar to that measured following surgical procedures (Smith et al 2005)

The strength increase observed is greater than that reported following chiropractic manipulation (Smith et al 2005)

The Case Report - ReferencesThe Case Report - References

No specific point value, but… No specific point value, but…

The strength of a report is dependent, in The strength of a report is dependent, in part, on the strength of its citations!part, on the strength of its citations!

Use primary literature sources Use primary literature sources – e.g. peer-reviewed articlese.g. peer-reviewed articles– Not secondary sources: Wikipedia, WebMDNot secondary sources: Wikipedia, WebMD– Textbooks? A few o.k.Textbooks? A few o.k.

Finding ReferencesFinding References

The searchThe search– From the literatureFrom the literature– Internet search engines: Pubmed.govInternet search engines: Pubmed.gov

The locatingThe locating– Some open accessSome open access– Libraries: generally University or MedicalLibraries: generally University or Medical– Contact the authorContact the author– Purchase from journalPurchase from journal

The readingThe reading

Insights into the Review ProcessInsights into the Review Process

The Reviewers (MTF)The Reviewers (MTF)

Group of 6 membersGroup of 6 members

Consists of Consists of – PractitionersPractitioners– EducatorsEducators– Researchers Researchers

Tips on Conducting the StudyTips on Conducting the Study

Use only one treatment modalityUse only one treatment modality

Use reliable measures to assess progressUse reliable measures to assess progress

Novelty of topic may trump quality of study Novelty of topic may trump quality of study

Synthesize data and present it only onceSynthesize data and present it only once

““Negative” data isn’t a show stopper, Negative” data isn’t a show stopper, but…. but….

Tips on Presenting the StudyTips on Presenting the Study

You don’t need to present all the data you You don’t need to present all the data you collectcollect

Don’t use “I” or “we” (“the author(s)”)Don’t use “I” or “we” (“the author(s)”)

Minimize use of direct quotesMinimize use of direct quotes

Be clear and conciseBe clear and concise

Other DocumentationOther Documentation

Informed Consent – Appendix DInformed Consent – Appendix D

HIPAA Guidelines – Appendix EHIPAA Guidelines – Appendix E

Photograph Release Form – Appendix FPhotograph Release Form – Appendix F

Proof of Liability Insurance Proof of Liability Insurance

Institutional Review Board Approval – not Institutional Review Board Approval – not required for a description of practice that required for a description of practice that does not involve research methodology. does not involve research methodology.