THE DESIGN AND PRESENTATION OF A CASE STUDY PETER J TUCHIN B.Sc., Grad.Dip.Chiro., Dip.OHS. * ROD BONELLO B.Sc., D.C., D.O., M.H.A. † INTRODUCTION previous publications by the author or if there are other publications in the area research that is applicable to the Case studies are a much maligned area of scientific grant. For example, with an Australian Spinal Research publication. However, they do form the initial basis of Foundation grant for chiropractic and migraine, a literature scientific knowledge, which can lead to further hypothesis review revealed only one large randomised controlled for investigation. trial, and only a few case studies. This can make the success of the grant application less likely because there is There are over 2500 chiropractors/osteopaths in Australia little support for the need to research the area, as well as with an estimated 15 million patient visits per year (1) . Yet few indications that research will reveal any benefits (3) . published case studies involving chiropractor/osteopath patients are minimal. Chiropractors/osteopaths often have However, by far the most important aspect is documentation many interesting cases to discuss and present, however, of anecdotal evidence of clinical improvement of individual some practitioners are uncertain of the best procedure to patients. If well presented case studies with strong objective publish these case reports. As a consequence, it would evidence can be published in sufficient numbers, then this appear that many conditions that have anecdotal support, becomes scientific evidence. have little if any scientific support (2) . CASE STUDY PRESENTATION One purpose of this paper is to present the standard features of case studies and to develop a criteria check-list The abstract precedes the body of the paper. It must be to evaluate the quality of case studies published. In concise and clear, as many readers will determine whether addition, the paper is designed to facilitate the publication they read the whole paper on the strength of the abstract. of more case studies by chiropractors/osteopaths about In performing literature reviews, many researchers the patients they consult in their practices. frequently scan hundreds if not thousands of abstracts. Therefore, a well structured abstract may determine the Practitioners will gain more information about conditions usefulness of the whole paper. that they encounter through a number of mechanisms. First, by reviewing the literature on the condition when A structured abstract is usually required for case study they prepare to write the case study. Secondly, through presentation, with the following sections included: reading other published case reports. Thirdly, when Objective; Clinical features; Intervention & Outcome; reading a case study it may motivate the practitioner to Conclusion. review any similar cases that they encountered in their own practice for comparison of their diagnosis and outcome Objective: To present and review the information of an of treatment. Finally, by discussing case reports they have unusual or interesting case study. Generally the objective read with other patients, there may be a chance of similar states what the case study will be reporting about, ie a case referral through these patients. patient that had rare, unusual or interesting features. Conversely, the patient may have had a very good or bad Another area for consideration is preparation of grant response to treatment for a more common condition. applications. The application often includes questions on Clinical features: This usually involves detailing the * Lecturer, unique aspects of the patient’s symptoms or signs. The Department of Chiropractic, section usually contains the important clinical features of Macquarie University the case including the patient history, physical examination † Director, results, neurological and orthopaedic findings, and other Department of Chiropractic, investigations (eg radiographs, blood or pathology tests, Macquarie University etc). Correspondence/Reprint Requests: Intervention & Outcome: Description of the intervention/ Peter J Tuchin B.Sc.(UNSW), Grad.Dip.Chiro., Dip.OHS treatment and details of how the outcome of treatment was Department of Chiropractic Suite 222, Building E7A measured. Macquarie University SYDNEY NSW AUSTRALIA 2109 Conclusion: The results of the intervention and any other Telephone: 61 2 9850 9380 Fax: 61 2 9850 9389 information, which is relevant for practitioners that may have similar cases. It is common to discuss what ACO 5 Volume 8 • Number 1 • March 1999
CASE STUDY PROCEDURES TUCHIN / BONELLO practitioners should note about the case or other It may also be appropriate to detail “at risk” groups, with recommendations for similar cases that they may encounter. particular reference to patients that commonly present with spinal pain or for SMT treatment. Key Indexing Terms - Medical Subject Headings (MeSH): Three to five medical subject headings or terms used for In addition, the introduction usually has a literature review indexing the paper for database retrieval. of standard features for these types of cases, including any “gold standard” for diagnosis. In conditions where a “gold Figure 1. standard” is not clearly identified or accepted, details should be given of how alternative methods of diagnosis CHECK LIST (5) . have been developed or tested Review your case presentation to assess whether each issue has been addressed. Some issues may not be easily identified, however, the more There may also be information regarding studies of patients information that can be included, the stronger the paper becomes. undergoing SMT for the same or similar conditions. It is 1. INTRODUCTION important to include this literature review information DEFINITION • because previous knowledge of the readers of the case MOST SUSCEPTIBLE • DESCRIPTION • study may be quite different to what is currently presented. AT RISK GROUP • INCIDENCE • 2. CASE FEATURES MORBIDITY/MORTALITY • AETIOLOGY • NATURAL HISTORY • This section contains all the important clinical features of 2. CASE FEATURES the case including the patient history, physical examination DESCRIPTIVE FEATURES • results, neurological and orthopaedic findings, and other CLINICAL HISTORY • EXAMINATION FINDINGS • investigations (eg radiographs, blood or pathology tests, OBJECTIVE TESTS • etc). Enough information should also be included to give SPECIFIC TESTS • other practitioners a clear understanding of the background 3. TREATMENT information for the patient. MANIPULATION: TYPE(S) • AREAS • The following represents a typical history of a case study ANCILLARY THERAPY • YES • NO for publication. It typically includes: EXERCISE • YES • NO MEDICAL TREATMENT • YES • NO CO-MANAGEMENT (IF ANY) • YES • NO i) A description of the presenting symptom(s); area of REFERRAL (WHO &/OR WHY) • YES • NO distribution; radiation of pain; paraesthesia or other sensory PREVENTATIVE MEASURES • YES • NO disturbance; causative factors; frequency and duration of 4. DISCUSSION symptom; aggravating and alleviating factors; 24 hour ALTERNATIVE TREATMENT • POTENTIAL FOR MISDIAGNOSIS • symptom distribution. CHIROPRACTIC SIGNIFICANCE • OTHER FEATURES ........................ ii) A clinical history which includes: operations; 5. CONCLUSION hospitalisations; serious illnesses; medications; accidents SUMMARY OF CASE (1-2 PARAGRAPHS) or falls; fractures; previous treatments or tests; radiographs; 6. REFERENCES relevant specialist consultations; and familial tendencies. SEE JOURNAL FOR CONFORMITY TO CORRECT METHOD iii) A “Systems review” including: History of headaches; ear, nose or throat conditions, gastrointestinal history; heart or lung conditions; bowel conditions; genito-urinary Case studies will usually contain the following information, system; endocrine function, orthopaedic and neurologic which is compiled in the sections detailed in the rest of this status and dermatological conditions. paper. A checklist has been included to allow the reader to review other case studies for their thoroughness and to iv) The following vascular investigations are usually provide a template for more case study publications. noted as well: Vertebral artery test; provocation test (eg. stressing the cervical spine in a pre-SMT position to 1. INTRODUCTION evaluate potential vertebrobasilar insufficiency); blood pressure assessment; abdominal aortic aneurysm screen. This section usually includes background information, including what the condition is, statistics on prevalence or In addition, this section usually involves detailing the incidence, who are likely to be affected and when, the unique or confusing aspects of the patients symptoms/ severity of the problem, mechanisms of how the condition signs, with particular reference to any objective tests that develops, potential causes of problem and how well the were performed. Case studies that have more objective aetiological factors have been tested for causal relationships tests such as spirometry, Doppler blood flow findings, (4) . ACO 6 Volume 8 • Number 1 • March 1999
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