Writing Case Reports.pdf

Volume 14 Number 3 2000 51INTRODUCTIONBackgroundShunned by some,adored by others,the clinical case report isthe foundational building block of scientific inquiry in healthcare(1).The case report is a specific type of research designthat reports on an aspect of the management of one or twopatients.Certain elements must be present in a case report inorder for it to be publication worthy(2,3).This article describeswhat is necessary in order to write a case report that is accept-able for publication in a peer-reviewed journal.This informa-tion will help new authors find the writing process easier andshould assist previously published authors with some tips forwriting their next case report.The chiropractic scientific community has reached a point ofmaturation where the case report is not regarded as simply anec-dotal information.Thus,the significance of the case report toprovide not only data but information about what occurs in clin-ical practice is being acknowledged and valued,especially sincecase reports are a foundation for experimental research.In addi-tion to the scientific communitys increased respect for casereports,these articles are interesting to journal readers since theinformation in case reports is practical and informative.Additionally,case reports are one of the best ways for authorsto get started in scholarly writing(4).Manuscripts received by journals are often returned to authorsimmediately because they are not formatted correctly or needfurther work to bring them in compliance with the acceptablestandards for publication.Manuscripts that are ready for peerreview,may require two or three passes through the peer reviewprocess before they are acceptable for publication.Most authorsappreciate and utilize the extra input and suggestions theyreceive from the peer review process,however,others find thisaggravating because it lengthens the time that it takes beforetheir manuscript can be published.Many of these problemscould be prevented if authors would prepare their manuscripts inthe appropriate format for scientific publications.Regardless of whether authors appreciate or disdain the peerWriting Patient Case Reports forPeer-reviewed Journals:Secrets of the TradeBart N.Green,MSEd,DC,DACBSP and Claire D.Johnson,MSEd,DC,DACBSPABSTRACTobjective:To describe and discuss the process used to write a case report for publication in a peer-reviewed journal.methods:Narrative review of the literature.discussion:The importance for case reports is presented as well as the explanation of how to write them in a standardized format.Steps in preparing a case report are described and discussed starting with selecting a title and concluding with preparing appropri-ate illustrations.conclusion:Case reports are important contributions to the health sciences literature.Proper preparation of this research design isnecessary in order for it to be published in a credible manner.key words:Case Report;Authorship;Peer Review,research;Manuscripts.Bart N.Green,MSEd,DC,DACBSPAssociate ProfessorPalmer Center for Chiropractic ResearchPalmer College of Chiropractic West90 E.Tasman Dr.San Jose,CA 95134(408)944-6190Green_Bpalmer.eduClaire D.Johnson,MSEd,DC,DACBSPAssociate Clinical ProfessorPalmer Center for Chiropractic ResearchPalmer College of Chiropractic WestCopyright 2000 ACA Sports Councilreview process,there are a few important principles listed intable 1 that most journals hold to dearly.These should be keptin mind when submitting a manuscript.Reasons for writing case report designsPrior to spending large amounts of time and energy on large-scale experimental research,it is important to document evi-dence of cases and their occurrence(5).This can be accom-plished by publishing case reports as the first line of evidence inclinical inquiry(1,6).Case reports are also essential for com-municating experiences encountered in clinical practice fromone clinician to another(1-3,5,7).Although some have regarded the case report design as triv-ial or anecdotal,there are many reasons why case reports pro-vide value to our literature base(1,7).For example,in 1985,the American Medical Association reprinted 51 papers fromthe Journal of the American Medical Association that had sig-nificantly changed the science and practice of medicine duringthe 150 years of the organizations existence.Interestinglyenough,five of these papers were case reports(8).In additionto contributing a first report of a clinical occurrence,casereports can be written for a variety of reasons,which are list-ed in table 2.52Journal of Sports Chiropractic&RehabilitationWriting Case Reports Green and JohnsonLimitations of case reportsWhile case reports are a valuable contribution to the literature,it must be kept in mind that they have certain limitations.Theselimitations are inherent properties of the design itself andinclude the following:patients are managed in a non-controlledenvironment,case reports cannot be generalized beyond thecontext of the case to a larger population of patients,and thenatural progression of disease or dysfunction may also explainresults experienced in patient care.First,the management of patients in an out-patient settingoccurs primarily in an uncontrolled environment.There is littlethe clinician can do to prevent patients from introducing a vari-ety of confounding factors into their lives that may also impactthe patients response to care.For example,chiropractors some-times use repetitive active movements into end range,such as inMcKenzie assessment,as a diagnostic procedure to assess ifpain moves in a peripheral manner with activity.If the chiro-practor later administers a chiropractic adjustment to thepatient,it is impossible to state whether the adjustment or therepetitive motion may have produced an effect on the patientcondition.Likewise,a patient may take pain relievers,lift aheavy object when not in the office,and may exhibit variouslevels of compliance with care,all which have an impact on theTable 1Important principles to remember when preparing a manuscript1.Format the manuscript according to the instructions forauthors which can be found in each journal.Otherwise,edi-tors will return it for correction without further review.2.Scholarly,peer-reviewed journals rely on expert review todetermine if the manuscript is of the quality to be publishedin the journal.A journal does not publish whatever materialis sent to it.Therefore,authors should submit their best andfinal draft for peer-review.“Concerned writers want onlytheir best efforts to be recorded for posterity.”(2).3.Rarely do seasoned authors have a manuscript accepted forpublication upon the first submission.It is expected thatsome revisions will be necessary prior to acceptance,there-fore patience and understanding are required.4.Editors will do their best to provide resources,advice andencouragement for potential authors.However,authors areresponsible for all of the writing and research.Table 2Reasons for submitting a case report for publication1.To present an unusual or unknown disorder(1,5).2.To present unusual etiology for a case(1).3.To present a challenging differential diagnosis(1).4.To describe mistakes in diagnosis,their causes and consequences(1).5.To describe an unusual setting for care(1).6.To present information that can not be reproduced due to ethical reasons(1,5).7.To illustrate a clinical hypothesis(7).8.To prompt a new hypothesis(3,5,7).9.To disconfirm an hypothesis(9).10.To support an hypothesis(3,7).11.To stimulate further research(7).12.To make an original contribution to the literature(5,10).13.To offer new insight into the pathogenesis of disease(3,4,10).14.To describe unusual or puzzling clinical features(3,4).15.To describe improved or unique technical procedures(2,4).16.To describe the historical development of a field or movement(11).Volume 14 Number 3 200053Writing Case Reports Green and Johnsonclinical picture seen by the clinician at the time of an officevisit.Because of these uncontrollable factors and the fact that thecare rendered to one patient may not produce the same effect inanother patient,case reports are limited in their generalizabilitybeyond the context of the patient reported(5,12).This meansthat one can never conclude,based upon the observations of asingle patient,that any particular management strategy will beeffective for other patients with the same condition(9).One canhypothesize this,but it can only be tested using experimentalclinical trials.However,authors of case reports may be encour-aged to know that design of more elaborate experimental trialsmay be based on the very work that they write.Results of patient responses to care are also limited by thenatural history of the disorder under study.Some disorders mayundergo spontaneous remission or phases of exacerbation andremission(12).Often times,one of these phases may corre-spond with the time when care is provided.For example,apatient with chronic adhesive capsulitis may present to theoffice at the peak of exacerbation.If the patient improves,it isdifficult to determine if the patient improved because of the nat-ural tendency for the capsulitis to enter a remission state or thecondition improved because of the care rendered.Similarly,ifthe patient presents just prior to the worst part of the inflamma-tory cycle and gets worse during care,it could seem as thoughthe care actually worsened the condition when in fact it may bethe natural disease process at work.Therefore the natural histo-ry must be kept in mind when managing patients and writing acase report.PRESENTATION STYLES OF CASE REPORTS The styles of case reports described below help authors presenttheir information to the reader.Case reports may be reported ina several manners including educational reports,diagnostic orassessment reports,and treatment or management reports.Educational case reportsEducational case reports are used to provide readers with up todate patient management strategies while providing a briefreview of the literature.This style may not add anything new tothe general base of scientific information,but provides an inter-esting form of continuing education and illustrates a sense of thetypical manifestation of a disorder so that atypical presentationscan be compared to it(3,7).Diagnostic/Assessment case reportsThis style of case report describes and discusses the diagnosticor analytic methods used to evaluate a patient.These cases pre-sent a diagnosis that is difficult to render,rare,or confusing.This form of case report presentation focuses on how the patientwas assessed and may report any follow up used in the case,butdoes not discuss treatment rendered to the patient(7,13).For example,Young describes a patient who presented with ahistory of recurrent headaches.She was diagnosed with a pitu-itary adenoma after magnetic resonance imaging was obtained.The case report described the diagnostic process,presented preand post-surgical images of the tumor site,and discussed thecondition(14).Since there was no chiropractic managementused in this case,treatment could not be discussed.Treatment/Management case reportsThis case report presentation style describes and discusses thefull management of a patient.How the patient is assessed andmanaged,including reporting the results of valid outcome mea-sures(7,13),provides the reader with an in-depth understand-ing of the case.THREE VARIETIES OF CASE REPORTSBased on the rigor of methods employed,there are three pri-mary varieties of case reports from which to choose,namelyretrospective case reports,prospective case reports,and timeseries designs.Retrospective case reportsThe retrospective design is the most commonly reported inthe literature(7).This variety is written after care for thepatient has been delivered,thus no previous research wasprepared prior to administering care.This type of report isthe simplest to write for publication and is an excellentdesign for the beginning writer to use.In essence,if a clini-cian utilizes valid and reliable outcome measures in dailypractice,has a specific management plan,writes clear chartnotes,and can write a report for an insurance company,thenmuch of what is needed to complete a retrospective casereport has been already accomplished.Often times one of thefaults of retrospective case reports is that authors do the bestjob possible while managing a case,but may not use the bestoutcome measures available because they do not know whatthey are.This fault detracts from the credibility of the reportand is something that can be avoided with some early plan-ning(7).Prospective case reportsProspective case reports differ from retrospective casereports in that the author actually plans out patient careahead of time.For example,a chiropractor may frequently54Journal of Sports Chiropractic&RehabilitationWriting Case Reports Green and Johnsonsee a number of patients with adhesive capsulitis of theglenohumeral joint.In preparation for a case report,this doc-tor reviews the literature to determine the best outcome mea-sures to assess patient progress and also learns how his or herplanned case will contribute to the literature.Published treat-ment protocols are also discovered and will be used once thenext patient presents with the condition.When the next casedoes arrive in the office,the clinician knows ahead of timeexactly how to evaluate the patient and will deliver a speci-fied predetermined management plan.Measurements of thepatients condition are taken before,during and after careand can be tracked over time.Some authors avoid this type of case report because somework is required prior to actually seeing the case.However,it actually saves an inordinate amount of time in the writingof the manuscript because the literature has been reviewedahead of time and the author will have used the most clini-cally appropriate outcome measures.An added bonus for thedoctor is that the early planning and preparation for this casereport improves the patient management in practice.Time series case reportsIn this design,a clinical hypothesis is generated by the doc-tor,tested over time,and documented with valid outcomemeasures(9).Time series designs are also prospective andpatient data is recorded at specified intervals before duringand after care is delivered(15,16).Each part of the study isbroken down into phases(12).A minimum of three measure-ments are taken on the patients condition during each phaseof the study thereby decreasing the likelihood that an inac-curate measurement is taken.Taking a series of three mea-surements also helps the author identify the trend of thepatients condition,something that can not be accomplishedif only one measurement is taken before and after care,which is typical in retrospective and prospective case reports(7,17).The most simple time series design is the“AB casereport”,where a minimum of three measurements are takenbefore care(A phase)and a minimum of three measurementsare taken during care(B phase)(7,12).More measuremen