Making the Case for Writing Case Reports Spring MNAPTA State Conference Brooklyn Center, MN April 15, 2011

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1 1 Making the Case for Writing Case Reports Spring MNAPTA State Conference Brooklyn Center, MN April 15, 2011 Mary Weddle, PT, DSc; John Schmitt, PT, PhD St. Catherine University DPT Program Minneapolis, MN Course Description This course will explore the role of case reports in the physical therapy literature and will provide PT/PTA clinicians with guidelines on how to write a case report. The structure, components, and types of case reports will be discussed, along with criteria for evaluating the quality of a published case report. Examples will be used from the physical therapy literature and previous state conference case report posters. Suggestions and guidelines will be given for presenting clinical cases at professional conferences or contributing to the professional literature by writing a case report for publication. Course Objectives At the end of this course, participants will be able to: 1. Describe the value of case reports within the larger context of scientific inquiry in physical therapist practice. 2. Describe the essential components (structure) of a case report. 3. Analyze the credibility of a published case report. 4. Identify patients/clients/topics in a physical therapy practice setting that might be appropriately described in case report format. 5. Describe opportunities for professional presentation of case reports (conferences, publications, poster presentation). 6. Identify resources to support a clinician in the process of writing a case report. 1

2 2 Introduction Why are case reports important? Case report in the larger context of scientific inquiry Descriptive research Evidence pyramid Quantitative and qualitative data What is qualitative research? Data gathered through interview, observation intensive investigation of the particular Conducted in a natural (vs lab) setting Psychology, sociology, anthropology Two paradigms of inquiry: o Positivist one truth (traditional scientific inquiry) o Constructivist multiple truths What is a case report? Rich description of practice o Does not establish cause and effect o Cannot generalize o Reader determines relevance to his/her practice (goal is not to convince reader of anything) General format for writing a case report exists, but there is no formal methodology May be a pilot study Like case law Case reports are not the same as: o Case study o Single subject design Purpose/Importance of case reports Provide thorough analysis of a single situation 2

3 3 Share clinic experience Share clinical reasoning process (get inside the mind of practitioner) Reduce variations in practice by comparing approaches May reveal relationships Mechanism to explicitly link literature to practice o Role in evidence based practice o May be first line of evidence, even though considered low level evidence (evidence pyramid) Bridge clinical practice and research Support/refute theory (deductive) Form basis of new theory (inductive) Focus of case reports Typically focuses a patient o A practice commonly used in the clinic, but not described in the literature o Atypical or novel intervention o Unusual patient / diagnosis o Diagnostic process Could be a group of patients, a facility, educational program, ethical issue, equipment use, administrative process 3

4 4 Components of Case Reports How to Critique Case Reports Parts/Structure of Case Report Title Abstract less that 350 words I. Introduction A. Literature review does not need to be exhaustive B. Theoretical construct of case report C. Purpose statement should appear at the very end of intro - The purpose of this case report is to describe D. Beware of case reports that claim to prove, demonstrate, or show cause and effect E. If pathology/intervention are very familiar, literature review may be brief; if novel, would be more extensive Case Report Critique Does the title clearly convey what case report is about? I. Introduction A. Literature review 1. What were the main categories of information covered in the lit review? Summarize what is being said in the lit review about each category (ie, what are the main points?). Were categories of information relevant to this case report why or why not? 2. Evaluate the sources cited by the author/s (primary, secondary; levels of evidence) 3. Does the literature review show how this case report fits into the literature currently available (i.e, does this case report fill a gap in current literature - explain?) B. Theoretical construct - Summarize the theoretical construct that the authors based the case report on (The Guide to PT Practice, function, NDT, etc). C. Problem Statement Does author explain why this subject is important? D. Purpose 1. What was the author s purpose for writing the case report? 2. Does the purpose statement appear at the end of the introduction? 3. Is the purpose appropriate for a case report? 4

5 5 II. Case Description A. History and description of the subject ( draw a picture for readers) B. Examination C. Evaluation/Diagnosis D. Prognosis - Based on literature, clinical judgment, or theoretical argument should be explicit which it is E. Description of Intervention II. Case Description A. Description of patient/subject / Patient history / Review of systems 1. Was description of patient thorough, relevant, presented in a fashion conductive to your thought processes (in the order that an expert would be thinking about the patient)? Why or why not? Look for: a. Relevant background/brief medical history/social history b. Indication of source of patient data/information c. Demographics d. History of current complaint or problem e. Prior or current treatment, including alternative or complementary medicine f. What the patient knows about their problem g. Is any qualitative data included - ie quotes of patient, family h. Goals of pt/family and how the goals were determined i. Does author explain their clinical impression of what is going on with the patient based on initial interview, chart review? Does author state why this particular patient is good candidate for the purpose of this case report. B. Examination 1. Is there an explanation of why tests/measures were done? Does author make their clinical decision making process clear to the reader? 2. Summarize measurements used, addressing reliability and validity. a. Does author explain (or operationalize) exam procedures well enough so that they could be replicated? Are published protocols cited? b. Are studies on reliability and validity of measurement tools cited? c. Discuss strengths and weaknesses of the author s use of measurements. 5

6 6 3. Was the use of tables and graphs helpful? Comment 4. Were impairments, functional limitation, and/or disabilities measured? 5. Is it clear what the outcome measures are? Are these outcome measures valid, reliable, and responsive and are sources cited to support this? C. Evaluation/Diagnosis 1. Does the author state a clinical hypothesis that is, evaluation and diagnosis? This should be author s clinical impression was initial impression confirmed/denied by exam data? 2. Were pathology/impairments/functional limitations/disabilities linked by the authors? D. Prognosis 1. What is the author s prognosis, including timeline? 2. Is the prognosis based on evidence from literature, presumptive argument, and/or clinical experience? E. Intervention-Plan of Care 1. What was POC and were any modifications made to the POC in order to achieve goals? 2. What is the author s rationale (or purpose statement) for each intervention? 3. Did author explain interventions and state exactly how interventions were delivered (parameters, frequency, dosage, progression)? Could you replicate them? 4. Were interventions modified during course of care? Why was this necessary? 5. Did the author use effective means of describing intervention (graphs, tables, results of intervention, etc)? Explain. 6. Did the author use an effective means to describe passage of time? That is, are dates given or was passage of time described in relative terms ( 4 months after injury ) 7. Did author report on patient adherence, motivation, attitude? 6

7 7 IV. III. Outcomes A. Quantitative (but do numbers tell it all??) B. Qualitative data C. Were patient goals met? Discussion A. Author s opinions and reflections B. Include possible explanations for what happened 1. Give alternative explanations for what happened 2. Authors shouldn t suggest cause/effect don t generalize C. Relate case report to literature how outcomes compare to literature D. Limitations or mistakes E. Specific suggestions for further research III. Outcomes A. Were pre and post intervention measurements given? B. Summarized outcomes including qualitative data? C. Did author discuss whether patient achieved goals? Is reason for patient discharge explained? IV. Discussion A. Are authors opinions clear? B. What explanations for the outcomes were given? Were alternative explanations given? What alternative explanations would you propose? Is clinical decision making clear? C. Does the author link the discussion back to the literature review? How do the case report findings compare to what is described in literature? Does author relate the discussion to the purpose of the report? D. Does author identify mistakes or errors that might have impacted outcomes? E. What further ideas for research were suggested? What additions would you make? Be specific. F. Does the author make appropriate conclusions for a case report (refrains from suggesting cause/effect, does not make generalization to populations) G. How is this case report applicable to the physical therapy field? V. References V. References A. Appropriate style used? B. Number of references appropriate? 7

8 8 VI. Credibility A. Credibility (believability) of case report Systematic data collection, repeated at intentional intervals Taking repeated measurements over time (before and after intervention) Reliable, valid, responsive outcome measures Triangulation of data using multiple methods and types of data to correlate with observed phenomena The authors should be explicit about assumptions, decision making Could have subject read case report, and state in the report that this was done VI. Credibility: Overall Critique of Case Report Discuss the credibility (believability) of this report. How did authors promote credibility? What could have been done better? Is informed consent mentioned? Written? Oral? Did patient read the case report prior to publication? Overall structure Did author organize the report in the 4 sections described above? If not, what structure was used? VII. Informed consent Must at least have verbal permission from patient; written consent may be required for publication VII. Check for documentation of informed consent in case report. 8

9 9 Support for writing case reports - How to make it happen Case report presentation opportunities - Sharing your work References APTA. Guidelines for the Submission of Case Reports to Physical Therapy. Cole B, Finch E, Gowland C, Mayo N. Physical Rehabilitation Outcome Measures. Hamilton, Ontario: BC Decker Inc; McEwen I, ed. Writing Case Reports: A How-to Manual for Clinicians. 3 rd Edition. Alexandria, VA: American Physical Therapy Association; Betker AL, et al. Game-based exercises for dynamic short-sitting balance rehabilitation of people with chronic spinal cord and traumatic brain injuries. Phys Ther. 2007;87(10): Fink ML, Stoneman PD. Deep Vein Thrombosis in an Athletic Military Cadet. J Orthop Sports Phys Ther. 2006;36(9):

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